Nokea
The practical nurse (PN) is assigned to work with three registered nurses (RN) who are caring for neurologically compromised clients. The client with which change in status is best to assign to the PN?
- A. Diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7
- B. Subdural hematoma whose blood pressure changed from 150/80 mmHg to 170/60 mmHg
- C. Myxedema coma whose blood pressure changed from 80/50 mmHg to 70/40 mmHg
- D. Viral meningitis whose temperature changed from 101° F (38.3 C) to 102° F (38.9C)
Correct Answer: D
Rationale: The correct answer is D because viral meningitis with a slight increase in temperature is less acute and complex compared to the other conditions. This change in temperature does not indicate a critical or urgent situation requiring immediate attention or intervention beyond the scope of a practical nurse. Choices A, B, and C present more significant changes in health status such as a decrease in Glasgow Coma Scale score, an increase in intracranial pressure indicated by blood pressure changes, and a significant drop in blood pressure, respectively. These changes require closer monitoring and intervention by registered nurses due to the higher acuity and complexity of care needed for these conditions.
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Which client should the nurse assess frequently because of the risk for overflow incontinence?
- A. A client who is bedfast, with increased serum BUN and creatinine levels
- B. A client with hematuria and decreasing hemoglobin and hematocrit levels
- C. A client who has a history of frequent urinary tract infections
- D. A client who is confused and frequently forgets to go to the bathroom
Correct Answer: A
Rationale: The correct answer is A. Bedfast clients with increased serum BUN and creatinine levels are at high risk for overflow incontinence. This occurs due to decreased bladder function and reduced ability to sense bladder fullness, leading to the bladder overfilling and leaking urine. Choice B describes symptoms related to possible urinary tract infections or renal issues, but these do not directly indicate overflow incontinence. Choice C, a history of frequent urinary tract infections, may suggest other urinary issues but not specifically overflow incontinence. Choice D, a confused client who forgets to go to the bathroom, is more indicative of functional incontinence rather than overflow incontinence.
A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 mmHg and he admits that he has not been taking the prescribed medication because the drugs make him feel bad. In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?
- A. Stroke secondary to hemorrhage
- B. Acute kidney injury due to glomerular damage
- C. Heart block due to myocardial damage
- D. Blindness secondary to cataracts
Correct Answer: A
Rationale: The correct answer is A: Stroke secondary to hemorrhage. Hypertension increases the risk of stroke due to the stress and damage it causes to blood vessels, which can lead to hemorrhage. Choice B is incorrect because acute kidney injury is more commonly associated with chronic uncontrolled hypertension, not acute elevations. Choice C is incorrect as heart block is not a direct consequence of hypertension. Choice D is incorrect as hypertension does not directly cause cataracts leading to blindness.
To manage the client's constipation, which suggestions should the nurse provide? (Select all that apply)
- A. Decrease laxative use to every other day and use oil retention enemas as needed.
- B. Include oatmeal with stewed prunes for breakfast as often as possible.
- C. Increase fluid intake by keeping a water glass next to the recliner.
- D. Recommend seeking help with regular shopping and meal preparation.
Correct Answer: C
Rationale: The correct answer is C. Increasing fluid intake is essential for managing constipation. Adequate hydration helps soften stool and promotes bowel movements. Choices A and B are incorrect as decreasing laxative use without medical advice and suggesting specific foods like oatmeal with stewed prunes may not be suitable for every individual with constipation. Choice D is also incorrect as while seeking help with meal preparation can indirectly aid in managing constipation, the immediate need is to increase fluid intake.
What action should the nurse implement for a female client with cancer who has a good appetite but experiences nausea whenever she smells food cooking?
- A. Encourage family members to cook meals outdoors and bring the cooked food inside
- B. Advise the client to replace cooked foods with a variety of different nutritional supplements
- C. Assess the client's mucus membranes and report the findings to the healthcare provider
- D. Instruct the client to take an antiemetic before every meal to prevent excessive vomiting
Correct Answer: A
Rationale: The correct action for the nurse to implement is to encourage family members to cook meals outdoors and bring the cooked food inside. This strategy can help reduce the smell of cooking food and potentially alleviate the client's nausea triggered by food smells. Assessing the client's mucus membranes (choice C) is not directly related to the client's symptom of nausea triggered by food smells. Instructing the client to take an antiemetic before every meal (choice D) may not address the root cause of the issue, which is the smell of cooking food. Advising the client to replace cooked foods with nutritional supplements (choice B) does not address the immediate problem of food odors triggering nausea.
A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client's serum laboratory value requires intervention by the nurse?
- A. Total calcium 9 mg/dl (2.25 mmol/L SI)
- B. Creatinine 4 mg/dl (354 micromol/L SI)
- C. Phosphate 4 mg/dl (1.293 mmol/L SI)
- D. Fasting glucose 95 mg/dl (5.3 mmol/L SI)
Correct Answer: B
Rationale: An elevated creatinine level indicates possible renal impairment, which requires intervention. High creatinine levels are associated with decreased kidney function, and in this case, it suggests potential renal issues due to long-term corticosteroid therapy. Monitoring renal function is crucial in clients with osteoporosis on corticosteroid therapy to prevent further complications. Total calcium levels within the normal range are suitable for a client with osteoporosis receiving calcium carbonate. Phosphate and fasting glucose levels do not directly indicate renal impairment in this scenario.