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Nurse caring for a client who reports severe sore throat, pain with swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?
- A. Prodromal
- B. Incubation
- C. Convalescence
- D. Illness
Correct Answer: D
Rationale: The correct answer is D: Illness. In this stage, the client exhibits specific signs and symptoms of infection, such as severe sore throat, pain with swallowing, and swollen lymph nodes. This indicates active replication of the pathogen and the body's immune response. Other choices are incorrect because: A: Prodromal is the initial stage with vague, non-specific symptoms. B: Incubation is the period between exposure to the pathogen and the onset of symptoms. C: Convalescence is the recovery stage after the illness.
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Nurse is caring for client who is 24h post-op following abdominal surgery. Nurse suspects client's pain management is inadequate. Which of following data reinforce suspicion? (Select all that apply.)
- A. Client seems easily agitated
- B. Client is nonadherent with coughing, deep breathing, dangling
- C. Client may have pain med every 4-6h but accepts it every 6-7h
- D. Client reports tenderness in his right lower leg
- E. Client's vital signs are heart rate 110/min, respiratory rate 20/min, temp 37C, BP 136/80 mmHg
Correct Answer: B, C, E
Rationale: The correct answers are B, C, and E. Choice B indicates client's nonadherence to post-op respiratory exercises may lead to inadequate pain management. Choice C shows client not taking pain meds as prescribed, suggesting inadequate pain relief. Choice E reveals elevated heart rate and BP, indicating physiological stress from pain. Choices A and D do not directly relate to pain management. Choice A may be due to discomfort but not necessarily indicative of inadequate pain management. Choice D's leg tenderness is not directly linked to post-op pain.
Nurse educator presenting on basic first aid for new home health nurses. She evaluates teaching as effective when new nurse states client who has heat stroke will have which of following?
- A. Hypotension
- B. Bradycardia
- C. Clammy skin
- D. Bradypnea
Correct Answer: A
Rationale: The correct answer is A: Hypotension. In heat stroke, the body's temperature regulation fails, leading to vasodilation and dehydration. This results in decreased blood pressure (hypotension) as the body struggles to cool down. Choices B (Bradycardia), C (Clammy skin), and D (Bradypnea) are not typical signs of heat stroke. Bradycardia is a slower heart rate, which is usually not seen in heat stroke as the body tries to cool itself. Clammy skin may be present in heat exhaustion but not necessarily in heat stroke. Bradypnea, or slow breathing, is not a common symptom of heat stroke, which is more associated with rapid breathing due to the body's attempt to cool down.
Nursing instructor is reviewing which actions nurses can initiate w/o provider's prescription. Students should identify which of following as nurse-initiated? (Select all that apply.)
- A. Give morphine sulfate 1-2 mg IV every 1h as needed for pain
- B. Insert NG tube to relieve client's gastric distension
- C. Show client how to use progressive muscle relaxation
- D. Perform daily bath after evening meal
- E. Re-position client every 2h to reduce pressure ulcer risk
Correct Answer: C, D, E
Rationale: Correct Answer: C, D, E
Rationale:
C: Showing a client how to use progressive muscle relaxation is an example of a nurse-initiated action as it involves client education and does not require a provider's prescription.
D: Performing a daily bath after the evening meal is a routine nursing care activity that can be initiated by the nurse without a provider's prescription.
E: Re-positioning a client every 2 hours to reduce the risk of pressure ulcers is an essential nursing intervention that can be initiated by the nurse without a provider's prescription.
Summary of Incorrect Choices:
A: Giving morphine sulfate IV every 1 hour as needed for pain requires a provider's prescription due to the administration of a controlled substance.
B: Inserting an NG tube to relieve gastric distension is an invasive procedure that typically requires a provider's order and specialized training.
Nurse is caring for client sitting in chair & asks to return to bed. Which is priority action for nurse to take at this time?
- A. Obtain walker for client to use to transfer back to bed
- B. Call for additional personnel to assist with transfer
- C. Use transfer belt & assist client to bed
- D. Assess client's ability to help with transfer
Correct Answer: D
Rationale: The correct answer is D: Assess client's ability to help with transfer. The priority action for the nurse is to evaluate the client's capability to assist with the transfer safely. This assessment is crucial to prevent any potential injury to the client during the transfer process. By determining the client's ability to help, the nurse can make an informed decision on the level of assistance required.
Choice A (Obtain walker), B (Call for additional personnel), and C (Use transfer belt) are all important interventions but assessing the client's ability to help is the priority as it informs the next steps in the transfer process. Without knowing the client's capacity to assist, the nurse cannot effectively determine the appropriate interventions needed.
Overall, assessing the client's ability to help with the transfer ensures the safety and well-being of the client during the transfer process.
Nurse counseling middle adult who describes having difficulty with many issues. Which problem should nurse identify as priority for more assessment & intervention?
- A. "I'm struggling to accept my parents are aging & need so much help"
- B. It's been so stressful for me to think about having intimate relationships
- C. I know I should volunteer my time for good cause, but maybe I'm just selfish
- D. I love my grandchildren, but my son expects me to relive my parenting days
Correct Answer: B
Rationale: The correct answer is B. The nurse should prioritize assessing and intervening in the middle adult's difficulty with intimate relationships because it can significantly impact their emotional well-being and ability to form healthy connections. Intimate relationships play a crucial role in one's overall quality of life and can affect various aspects of mental health. By addressing this issue first, the nurse can help the individual work through their stress and potentially improve their relationships and overall psychological health.
Choices A, C, and D are not as critical as choice B because they involve different aspects of the individual's life that may not have an immediate impact on their emotional well-being and relationships. While accepting aging parents or volunteering are important, they do not directly address the middle adult's current emotional distress. Similarly, the expectation from the son regarding grandparenting, while challenging, may not be as urgent as addressing the stress related to intimate relationships.