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A client with deep vein thrombosis (DVT) in the left leg is on a heparin protocol. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Observe for bleeding side effects related to heparin therapy.
- B. Assess blood pressure and heart rate at least every 4 hours.
- C. Measure calf girth to evaluate edema in the affected leg.
- D. Encourage mobilization to prevent pulmonary embolism.
Correct Answer: A
Rationale: The correct answer is to 'Observe for bleeding side effects related to heparin therapy.' This is the most crucial intervention for a client with deep vein thrombosis (DVT) on a heparin protocol. Heparin, being an anticoagulant, increases the risk of bleeding as a side effect. Therefore, close monitoring for signs of bleeding, such as bruising, petechiae, or blood in stool or urine, is essential to prevent severe complications. While assessing blood pressure and heart rate (Choice B) is important, it is not as critical as monitoring for bleeding. Measuring calf girth (Choice C) may help evaluate edema but is not as vital as observing for bleeding complications. Encouraging mobilization (Choice D) is beneficial for preventing complications like pulmonary embolism, but in this scenario, monitoring for bleeding takes precedence due to the immediate risk associated with anticoagulant therapy.
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The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which outcome indicates that the program was effective?
- A. Clients who developed disease complications promptly received rehabilitation
- B. More than 50% of at-risk clients were diagnosed early in their disease process
- C. Only 30% of clients did not attend self-management education sessions
- D. Average client scores improved on a specific risk factor knowledge test
Correct Answer: A
Rationale: The correct answer is A because in tertiary prevention, the focus is on managing complications and providing rehabilitation. Choice B is more aligned with primary prevention as it focuses on early diagnosis. Choice C's attendance in education sessions is not a direct indicator of managing complications. Choice D's improvement in knowledge does not directly measure the program's effectiveness in managing complications.
The nurse assesses a 5-year-old child who has been experiencing frequent headaches and vomiting. The nurse notices that the child is lethargic and has a positive Brudzinski sign. Which action should the nurse implement first?
- A. Perform a complete neurological examination
- B. Measure the child's head circumference
- C. Check the child's blood glucose level
- D. Notify the healthcare provider immediately
Correct Answer: D
Rationale: The correct action for the nurse to implement first is to notify the healthcare provider immediately. The presence of lethargy and a positive Brudzinski sign in a child experiencing frequent headaches and vomiting may indicate a serious condition like meningitis. Prompt notification of the healthcare provider is crucial for timely evaluation and initiation of appropriate treatment.
Choice A is incorrect because while a neurological examination may be necessary, it is not the priority when a potentially serious condition like meningitis is suspected.
Choice B is incorrect as measuring the child's head circumference is not the most immediate action to take in this situation.
Choice C is also incorrect as checking the child's blood glucose level, although important in some cases, is not the priority when a child presents with symptoms suggestive of meningitis.
A client with major depression who is taking fluoxetine calls the psychiatric clinic reporting being more agitated, irritable, and anxious than usual. Which intervention should the nurse implement?
- A. Tell the client to have a complete blood count (CBC) drawn
- B. Instruct the client to seek medical attention immediately
- C. Encourage them to take the medication at night with a snack
- D. Explain that these are common side effects of the medication
Correct Answer: B
Rationale: Increased agitation, irritability, and anxiety can be signs of serotonin syndrome or other serious side effects, not common side effects of fluoxetine. Instructing the client to seek medical attention immediately is crucial to address any potential serious adverse reactions. Option A is unnecessary as a CBC would not address the symptoms described. Option C is not the priority when serious side effects are suspected. Option D is incorrect as these symptoms should not be dismissed as common side effects.
Several clients on a busy antepartum unit are scheduled for procedures that require informed consent. Which situation should the nurse explore further before witnessing the client's signature on the consent form?
- A. The client was medicated for pain with a narcotic analgesic IM 6 hours ago
- B. A 15-year-old primigravida who has been self-supporting for the past 6 months
- C. The obstetrician explained a procedure that a neurologist will perform
- D. The client is illiterate but verbalizes understanding and consent for the procedure
Correct Answer: D
Rationale: The correct answer is D because an illiterate client may require additional support to ensure they fully comprehend the information provided in the informed consent process. It is crucial to confirm that the client truly understands the nature of the procedure, its risks, and benefits. While it is important to assess pain control (choice A), a client's previous medication administration does not directly impact their ability to understand the consent process. Choice B, a 15-year-old primigravida who has been self-supporting, may legally provide informed consent depending on the jurisdiction and circumstances, so this situation may not require further exploration. Choice C, explaining a procedure by a different specialist, does not necessarily require additional exploration before witnessing the client's consent.
A young female adult wanders into the Emergency Department. She is disheveled and confused and states, 'My date must have put something in my drink. He took my car, and I think he raped me. I don't exactly remember, but I know he hurt me.' How should the nurse respond?
- A. Did you try to resist or fight back when you felt uncomfortable?
- B. He hurt you? Can you elaborate on what happened?
- C. It is okay to cry, but first, let's address your injuries and the situation.
- D. Yes, I can see. Tell me more about what you remember.
Correct Answer: D
Rationale: The correct response is to encourage the patient to share more about what she remembers. This approach helps gather crucial information, supports the patient in a non-judgmental manner, and allows the nurse to provide appropriate care. Choice A has been revised to be more sensitive by asking about resistance when feeling uncomfortable rather than placing blame. Choice B has been adjusted to show empathy and request more details without questioning the patient's account. Choice C, although empathetic, does not address the immediate need to collect information and support the patient.