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An older client is admitted to the psychiatric unit for assessment of a recent onset of dementia. The PN notes that in the evening this client often becomes restless, confused, and agitated. Which intervention is most important for the PN to implement?
- A. Ask family members to remain with the client in the evenings from 5 to 8 pm
- B. Administer a prescribed PRN benzodiazepine at the onset of a confused state
- C. Ensure that the client is assigned to a room close to the nurses' station
- D. Postpone administration of nighttime medications until after 11 pm
Correct Answer: C
Rationale: Sundowning, a phenomenon where dementia symptoms worsen in the evening, can be managed by ensuring the client is close to the nurses' station for frequent monitoring and quick intervention, if necessary. This reduces the risk of harm and helps manage agitation. Asking family members to remain with the client may not always be feasible and does not address the need for close monitoring. Administering benzodiazepines should not be the first-line intervention for sundowning as it can increase the risk of falls and other adverse effects. Postponing medication administration may disrupt the client's routine and potentially worsen symptoms.
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A client has a prescription for a transcutaneous electrical nerve stimulator (TENS) unit for pain management during the postoperative period following a lumbar laminectomy. Which information should the PN reinforce about the action of the adjuvant pain modality?
- A. The discharge of electricity will distract the client's focus from the pain.
- B. An infusion of medication into the spinal canal will block pain perception.
- C. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus.
- D. A mild electrical stimulus on the skin surface closes the gates of nerve conduction for severe pain.
Correct Answer: D
Rationale: The TENS unit works by providing a mild electrical stimulus to the skin, which helps to 'close the gate' on pain signals, reducing the perception of pain. Choice A is incorrect because distraction is not the primary mechanism of action for TENS. Choice B is incorrect as it describes a different method of pain management involving medication infusion into the spinal canal. Choice C is incorrect as it inaccurately describes the location of pain perception modulation by the TENS unit.
Which of the following best describes the role of insulin in the body?
- A. Insulin helps break down glucose into energy for the body
- B. Insulin facilitates the movement of glucose into cells
- C. Insulin converts excess glucose into fat for storage
- D. Insulin increases the breakdown of protein into amino acids
Correct Answer: B
Rationale: The correct answer is B: Insulin facilitates the movement of glucose into cells. Insulin is a hormone that helps regulate blood sugar levels by promoting the uptake of glucose from the bloodstream into cells, where it can be used for energy production. Choice A is incorrect because insulin doesn't break down glucose but rather helps cells take up glucose. Choice C is incorrect as insulin does not directly convert glucose into fat; excess glucose is stored as fat by other processes. Choice D is incorrect as insulin does not increase the breakdown of protein into amino acids; its primary role is in glucose metabolism.
A client with uterine cancer asks the nurse, 'Which is the most common type of cancer in women?' The nurse replies that it is breast cancer. Which type of cancer causes the most deaths in women?
- A. Breast cancer
- B. Lung cancer
- C. Brain cancer
- D. Colon and rectal cancer
Correct Answer: B
Rationale: Lung cancer is the leading cause of cancer-related deaths in women, surpassing even breast cancer. While breast cancer is more common, it is often detected early enough for effective treatment. Lung cancer, on the other hand, tends to be diagnosed at later stages, leading to higher mortality rates. Brain cancer and colon and rectal cancer are not the leading causes of cancer-related deaths in women, making them incorrect choices.
Which of the following is the best method for confirming nasogastric tube placement?
- A. Auscultating over the stomach while injecting air
- B. Checking the pH of the aspirate
- C. Observing the patient's response during feeding
- D. Measuring the external length of the tube
Correct Answer: B
Rationale: Checking the pH of the aspirate is the most reliable method to confirm nasogastric tube placement as it provides direct evidence of the tube's location in the stomach. When the pH is acidic (pH < 5), it indicates that the tube is correctly placed in the stomach. Auscultating over the stomach while injecting air may not always be accurate, as the sound can be misleading due to various factors. Observing the patient's response during feeding is not a definitive method for confirming tube placement, as it can be influenced by other factors. Measuring the external length of the tube does not ensure correct placement within the GI tract and can be affected by external factors like patient anatomy.
A homeless male client with a history of alcohol abuse had a CVA 10 years ago that resulted in left hemiparesis. Today he is brought to the clinic reporting pain in his left leg. He is afebrile, has 4+ pitting edema in the lower left leg, and has minimal swelling of the right leg. Which action should the PN implement first?
- A. Obtain a blood alcohol test
- B. Inspect legs for infection or trauma
- C. Complete a mental status exam
- D. Inquire about dietary salt intake
Correct Answer: B
Rationale: Inspecting the legs for infection or trauma is the priority to assess the cause of the pain and edema, which could indicate deep vein thrombosis or cellulitis. Checking for signs of infection or trauma is crucial in this scenario to rule out potentially serious conditions. Obtaining a blood alcohol test, completing a mental status exam, or inquiring about dietary salt intake can be considered after addressing the immediate concern of identifying any infection or trauma in the leg.