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A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions?
- A. Shrugs his shoulders
- B. Sticks his tongue out
- C. Frowns symmetrically
- D. Identifies a sour taste
Correct Answer: A
Rationale: The correct answer is A: Shrugs his shoulders. Cranial nerve XI, also known as the spinal accessory nerve, is responsible for controlling the trapezius and sternocleidomastoid muscles, which are involved in shoulder shrugging. When the nurse asks the client to shrug his shoulders against resistance, she is testing the integrity of cranial nerve XI. This action allows the nurse to assess the strength and function of this particular cranial nerve.
Choices B, C, and D are incorrect because they test other cranial nerves. Sticking the tongue out (B) tests cranial nerve XII (hypoglossal nerve), frowning symmetrically (C) tests cranial nerve VII (facial nerve), and identifying a sour taste (D) tests cranial nerve IX (glossopharyngeal nerve). These actions do not involve cranial nerve XI and are therefore not indicators of its intactness.
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A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications?
- A. Acetylcysteine
- B. Protamine
- C. Naloxone
- D. Flumazenil
Correct Answer: C
Rationale: The correct answer is C: Naloxone. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, such as respiratory depression. In this case, the client's respiratory rate of 10/min indicates opioid overdose due to hydromorphone. Naloxone administration can help reverse the respiratory depression and restore normal breathing.
Choice A: Acetylcysteine is used for acetaminophen overdose, not opioid overdose.
Choice B: Protamine is used to reverse the effects of heparin, not opioids.
Choice D: Flumazenil is a benzodiazepine antagonist, not an opioid antagonist.
Therefore, the most appropriate choice in this scenario is Naloxone to address the opioid overdose and respiratory depression.
A community health nurse is working with a family that is struggling to adapt following the loss of a family member. Which of the following actions should the nurse take first?
- A. Refer the family to a grief support group
- B. Determine the roles of individual family member
- C. Encourage the family to assign specific tasks to individual family members.
- D. Assist the family to establish a daily routine.
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This should be the first action because understanding each family member's roles can help identify their needs, strengths, and how they can support each other. By determining roles, the nurse can establish a foundation for building effective coping strategies and addressing specific concerns within the family unit.
Incorrect choices:
A: Refer the family to a grief support group - This could be beneficial later on, but it's important to first understand the family dynamics and individual roles.
C: Encourage the family to assign specific tasks to individual family members - Assigning tasks may not address the underlying emotional needs of the family members.
D: Assist the family to establish a daily routine - While routines can be helpful, understanding roles is crucial for tailoring the routine to the family's specific situation.
A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse?
- A. A client who requests assistance to use the bedside commode
- B. A client who has a prescription for compression stockings and did not receive them
- C. A client who requests to sit in the bedside chair while watching TV
- D. A client who consumes all the food from their meal tray
Correct Answer: B
Rationale: Correct Answer: B - A client who has a prescription for compression stockings and did not receive them should be reported to the nurse.
Rationale: Compression stockings are a prescribed medical intervention for a specific reason, such as preventing blood clots or managing edema. Failure to provide them can lead to serious health consequences. The nurse needs to be informed immediately to address this issue promptly.
Summary of Other Choices:
A: A client requesting assistance to use the bedside commode is within the scope of the AP's duties and does not require immediate nurse intervention.
C: A client requesting to sit in a bedside chair is a basic comfort measure and does not require immediate nurse intervention.
D: A client consuming all the food from their meal tray is not a cause for immediate concern and does not require nurse intervention at that moment.
A nurse is planning care for a client who has acute appendicitis. Which of the following actions should the nurse plan to take?
- A. Place the client's head of bed flat
- B. Apply heat to the client's abdomen
- C. Keep the client on NPO status
- D. Administer a laxative to the client.
Correct Answer: C
Rationale: The correct answer is C: Keep the client on NPO status. This is essential to prevent exacerbation of appendicitis by reducing the risk of bowel obstruction or rupture. Allowing the intestine to rest helps decrease inflammation and pain. Placing the client's head of bed flat (A) can increase intra-abdominal pressure, worsening the condition. Applying heat to the abdomen (B) can mask symptoms and potentially lead to delay in diagnosis. Administering a laxative (D) is contraindicated as it can increase the risk of perforation. In summary, maintaining NPO status is crucial for managing acute appendicitis effectively.
A nurse is planning care for a group of clients and is working with one licensed practical nurse (LPN) and one assistive personnel (AP). Which of the following actions should the nurse take first to manage her time effectively?
- A. Delegate tasks to the AP
- B. Determine goals of the day.
- C. Develop an hourly time frame for tasks
- D. Schedule daily activities
Correct Answer: B
Rationale: The correct answer is B: Determine goals of the day. This is the first step to managing time effectively as it helps prioritize tasks and establish a clear direction for care delivery. By setting goals, the nurse can focus on important tasks, delegate appropriately, and allocate time efficiently.
A: Delegating tasks to the AP can come after determining goals to ensure tasks are aligned with priorities.
C: Developing an hourly time frame for tasks can be done once goals are established to create a detailed schedule.
D: Scheduling daily activities is important but should be based on the goals set for the day.
In summary, determining goals of the day is the initial step in time management as it provides a framework for prioritizing tasks and organizing activities efficiently.