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A 14-year-old boy fell off his bike while 'popping a wheelie' on the dirt trails. He has sustained a head injury with laceration of his scalp over his temporal lobe. If he were to complain of headache during the first 24 hours of his hospitalization, the nurse would:
- A. Ask the physician to order a sedative
- B. Have the client describe his headache every 15 minutes
- C. Increase his fluid intake to 3000 mL/24 hr
- D. Offer diversionary activities
Correct Answer: D
Rationale: Diversion may help the child to focus on a pleasant activity instead of on his headache.
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The health team needs to realize that the compulsive concern with cleanliness that a client with severe anxiety exhibits is most likely an attempt to:
- A. Reduce his anxiety
- B. Avoid going to psychotherapy
- C. Manipulate the health team members
- D. Increase his self-image by showing higher standards than the fellow clients
Correct Answer: A
Rationale: These behaviors are attempts to relieve anxiety, as compulsive actions often serve as a coping mechanism for severe anxiety.
The client returns to the unit from surgery with a blood pressure of 90/50, pulse 132, respirations 30. Which action by the nurse should receive priority?
- A. Continue to monitor the vital signs
- B. Contact the physician
- C. Ask the client how he feels
- D. Ask the LPN to continue the post-op care
Correct Answer: B
Rationale: Hypotension (BP 90/50), tachycardia (pulse 132), and tachypnea (respirations 30) indicate potential shock or hemorrhage post-surgery, requiring immediate physician notification. Monitoring is secondary, and delegating or asking about feelings delays intervention.
A client is a victim of domestic violence. She is now receiving assistance at a shelter for battered women. She tells the nurse about the cycle of violence that she has been experiencing in her relationship with her husband of 5 years. In the 'tension-building phase,' the nurse might expect the client to describe which of the following?
- A. Promises of gifts that her husband made to her
- B. Acute battering of the client, characterized by his volatile discharge of tension
- C. Minor battering incidents, such as the throwing of food or dishes at her
- D. A period of tenderness between the couple
Correct Answer: C
Rationale: This description is characteristic of the 'tension-building' phase prior to the volatile discharge of tension found in the battering phase.
Before administering a client's morning dose of Lanoxin (digoxin), the nurse checks the apical pulse rate and finds a rate of 54. The appropriate nursing intervention is to:
- A. Record the pulse rate and administer the medication
- B. Administer the medication and monitor the heart rate
- C. Withhold the medication and notify the doctor
- D. Withhold the medication until the heart rate increases
Correct Answer: C
Rationale: A pulse rate below 60 bpm indicates bradycardia, a contraindication for digoxin due to the risk of worsening heart block. The nurse should withhold the dose and notify the physician.
The doctor has ordered antithrombotic stockings to be applied to the legs of a client with peripheral vascular disease. The nurse knows antithrombotic stockings should be applied:
- A. Before the client arises in the morning
- B. With the client in a standing position
- C. After the client has bathed and applied lotion to the legs
- D. Before the client retires in the evening
Correct Answer: A
Rationale: Antithrombotic stockings should be applied before the client arises in the morning when edema is minimal, ensuring proper fit and maximum compression to promote venous return. Applying them later or after lotion can reduce effectiveness or cause skin irritation.