Nokea
Which of the following actions should the nurse take?
- A. Assist the caregiver to arrange a daycare program for the client.
- B. Advise the caregiver to take time for themselves when possible.
- C. Encourage the caregiver to focus on the positive aspects of caregiving.
- D. Remind the caregiver that their loved one depends on them completely.
Correct Answer: A
Rationale: The correct answer is A because arranging a daycare program for the client allows the caregiver to have a break and attend to their own needs. This promotes self-care, prevents burnout, and ensures the well-being of both the caregiver and the client. Choice B, advising the caregiver to take time for themselves, is not as effective as it doesn't provide a concrete solution like arranging daycare. Choice C, encouraging the caregiver to focus on the positive aspects, may be helpful but does not address the need for respite. Choice D, reminding the caregiver of their loved one depending on them, may increase guilt and stress.
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A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?
- A. Offer small amounts of clear liquids 6 hr following surgery
- B. Administer analgesics on a scheduled basis for the first 24 hr
- C. Give cromolyn nebulized solution every 8 hr
- D. Apply a warm compress to the operative site every 4 hr
Correct Answer: B
Rationale: The correct answer is B: Administer analgesics on a scheduled basis for the first 24 hr. Postoperative pain management is crucial for the comfort and well-being of the child. Scheduled analgesics help maintain a consistent level of pain relief, preventing peaks and valleys in pain intensity. This approach is especially important in the initial 24 hours following surgery when pain is typically more intense. Offering small amounts of clear liquids 6 hours post-surgery (Choice A) may not be appropriate as the child may still be recovering from anesthesia and at risk of nausea or vomiting. Giving cromolyn nebulized solution every 8 hours (Choice C) is not indicated for postoperative pain management. Applying a warm compress to the operative site every 4 hours (Choice D) may provide some comfort but does not address the underlying need for analgesia.
The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process.
- A. Hemoglobin
- B. Alanine aminotransferase (ALT)
- C. Blood pressure
- D. Platelet count
Correct Answer: C,D
Rationale: Sure, here is the step-by-step rationale for why options C and D (Platelet count) are correct:
1. Blood pressure: In preeclampsia, high blood pressure is a key characteristic. Elevated blood pressure is a common finding in patients with preeclampsia, making option C consistent with preeclampsia.
2. Platelet count: HELLP syndrome is a serious complication of preeclampsia characterized by Hemolysis, Elevated Liver enzymes, and Low Platelet count. Therefore, a low platelet count is a hallmark feature of HELLP syndrome, aligning with option D.
Summary:
- Hemoglobin (Option A): Hemoglobin levels are not specific to either preeclampsia or HELLP syndrome. Therefore, this option is not selected.
- Alanine aminotransferase (ALT) (Option B): Elevated ALT levels are more specific to HELLP syndrome due to liver involvement. However, ALT
The nurse should recognize that which of the following findings is a complication of immobility
- A. Increased BP
- B. Urinary frequency
- C. Swollen area on calf
Correct Answer: C
Rationale: The correct answer is C: Swollen area on calf. Immobility can lead to blood pooling in the lower extremities, causing swelling, pain, and potentially leading to deep vein thrombosis (DVT). This is a serious complication that can result from prolonged periods of immobility. Increased blood pressure (choice A) is not typically a direct complication of immobility. Urinary frequency (choice B) is more commonly associated with conditions like urinary tract infections or overactive bladder, not immobility. Swollen area on the calf (choice C) is a hallmark sign of potential DVT in immobile patients.
For each assessment finding, click to specify if the finding is consistent with psychosis or mania.
- A. Hallucinations
- B. Lack of sleep
- C. Excessive spending habits
- D. Disorganized thought process
- E. Pressured speech
Correct Answer: A,B,C,D,E
Rationale: The correct answer is A, B, C, D, E. Hallucinations, lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are all consistent with both psychosis and mania. Hallucinations are sensory perceptions without a real external stimulus, common in both conditions. Lack of sleep is a hallmark symptom of mania and can also exacerbate psychotic symptoms. Excessive spending habits are often seen in manic episodes due to impulsivity, and disorganized thought process and pressured speech are characteristic of both psychosis and mania, reflecting the underlying cognitive and communication disturbances. Other choices are not specific or commonly associated with psychosis or mania.
Which of the following actions should the nurse take?
- A. Maintain the irrigation solution rate.
- B. Increase the irrigation solution rate.
- C. Clamp the catheter for 30 minutes and reassess.
- D. Notify the provider immediately.
Correct Answer: A
Rationale: The correct answer is A: Maintain the irrigation solution rate. This is the appropriate action because maintaining the irrigation solution rate ensures continuous flushing of the catheter to prevent blockages and maintain patency. Increasing the rate could lead to complications like fluid overload. Clamping the catheter and reassessing can cause catheter obstruction. Notifying the provider immediately may not be necessary unless there are specific complications or concerns.