Nokea
A 19-year-old male client arrived via ambulance to the emergency room following a motorcycle accident. He is comatose. His face has evidence of dried blood. On assessment, the nurse notes an obvious injury to his left eye. The preferred positioning for a client with an obvious eye injury is:
- A. Reclining to control bleeding
- B. Any position in which the client is comfortable
- C. Side-lying, either left or right
- D. Sitting with head support
Correct Answer: D
Rationale: A reclining position can cause a penetrating object to advance further into the eye. Prevention of further injury is the priority, not comfort. A side-lying position may increase intraocular and intracranial pressure if an accompanying head injury is suspected. A sitting position with the head supported will prevent further injury while allowing injury care to take place.
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A 23-year-old male client is admitted to the chemical dependency unit with a medical diagnosis of alcoholism. He reports that the last time he drank was 3 days ago, and that now he is starting to 'feel kind of shaky.' Based on the information given above, nursing care goals for this client will initially focus on:
- A. Self-concept problems
- B. Interpersonal issues
- C. Ineffective coping skills
- D. Physiological stabilization
Correct Answer: D
Rationale: Self-concept and self-esteem problems may emerge during the client's treatment, but these are not immediate concerns. Interpersonal issues may become evident during the course of the client's treatment, but these are also not immediate areas of concern. Improving individual coping skills is generally a primary focus in the treatment and nursing care of persons with substance abuse problems. However, this is still not the immediate concern in this client situation. Correction of fluid and electrolyte status and vitamin deficiencies, as well as prevention of delirium, is the immediate concern in the care of this client.
The nurse teaches a male client ways to reduce the risks associated with furosemide therapy. Which of the following indicates that he understands this teaching?
- A. I'll be sure to rise slowly and sit for a few minutes after lying down.'
- B. I'll be sure to walk at least 2-3 blocks every day.'
- C. I'll be sure to restrict my fluid intake to four or five glasses a day.'
- D. I'll be sure not to take any more aspirin while I am on this drug.'
Correct Answer: A
Rationale: Rising slowly prevents postural hypotension, a common side effect of furosemide that increases fall risk. The other options are not specific to furosemide therapy risks.
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.
A young boy tells the nurse, 'I don't like my Dad to kiss or hug my Mom. I love my Mom and want to marry her.' The nurse recognizes this stage of growth and development as:
- A. Electra complex
- B. Oedipus complex
- C. Superego
- D. Ego
Correct Answer: B
Rationale: The Oedipus complex involves a young boy's erotic attachment to his mother and jealousy toward his father.
A client with cervical cancer has a radioactive implant. Which statement indicates that the client understands the nurse's teaching regarding radioactive implants?
- A. I won't be able to have visitors while getting radiation therapy.
- B. I will have a urinary catheter while the implant is in place.
- C. I can be up to the bedside commode while the implant is in place.
- D. I won't have any side effects from this type of therapy.
Correct Answer: C
Rationale: Clients with radioactive implants can use the bedside commode if permitted, indicating understanding of mobility restrictions. Visitor limitations, catheters, and side effects depend on the specific protocol.