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A 26-year-old client has no children. She has had an abdominal hysterectomy. In the first 24 hours postoperatively, the nurse would be concerned if the client:
- A. Cries easily and says she is having abdominal pain
- B. Develops a temperature of 102°F
- C. Has no bowel sounds
- D. Has a urine output of 200 mL for 4 hours
Correct Answer: B
Rationale: The client may be more tearful than normal due to the stress of the surgery and its implications for her future life. She would be expected to have pain following surgery. A temperature of 102°F indicates an infectious process. This is not a normal sequence to surgery and indicates a need for further assessment. The client is expected to have no bowel sounds for 24-48 hours after surgery because of the trauma to the bowel. Normal urine output is 30 mL/hr. This represents an output of 50 mL/hr, which is greater than normal.
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A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe anxiety disorder. The first nursing action is to:
- A. Demand that she relax
- B. Ask what is the problem
- C. Stand or sit next to her
- D. Give her something to do
Correct Answer: C
Rationale: Standing or sitting next to the client conveys caring and provides a sense of security, reducing anxiety.
A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:
- A. Must use the least restrictive measure possible to control the behavior
- B. Should put the client in seclusion until he promises to behave appropriately
- C. Should apply full restraints until the behavior is under control
- D. Should allow other clients to observe the acting out so that they can learn from the experience
Correct Answer: A
Rationale: This answer is correct. Least restrictive measures should always be attempted before a client is placed in seclusion or restraints. The nurse should first try a calm verbal approach, suggest a quiet room, or request that the client take 'time-out' before placing the client in seclusion, giving medication as necessary, or restraining. This answer is incorrect. A calm verbal approach or requesting that a client go to his room should be attempted before restraining. This answer is incorrect. Restraints should be applied only after all other measures fail to control the behavior. (D Seniors) This answer is incorrect. Other clients should be removed from the area. It is often very anxiety producing for other clients to see a peer out of control. It could also lead to mass acting-out behaviors.
In working with mental health clients who are prescribed medication that must be taken on a routine basis, it is important for education to begin when the drug therapy is initiated. One of the first steps in the teaching process is to:
- A. Explain the side effects of the medication
- B. Discuss the danger of overmedication
- C. Distribute written material to supplement verbal instructions
- D. Explore the client's perception regarding medication therapy
Correct Answer: D
Rationale: (A, B, C) The nurse must first obtain information regarding the client's perception of the medication regimen. The first step in the teaching process is to determine the client's perception.
The nurse is preparing to administer a dose of warfarin (Coumadin). The client’s INR is 3.5. What action should the nurse take?
- A. Administer the dose as ordered.
- B. Withhold the dose and notify the physician.
- C. Double the dose to achieve therapeutic range.
- D. Administer half the dose.
Correct Answer: B
Rationale: An INR of 3.5 is above the therapeutic range (2–3 for most conditions), indicating increased bleeding risk. The nurse should withhold the dose and notify the physician for further orders. Adjusting the dose independently is unsafe.
A 14-year-old boy has had diabetes for 7 years. He takes 30 U of NPH insulin and 10 U of regular insulin every morning at 7 AM. He eats breakfast at 7:30 AM and lunch at noon. What time should he expect the greatest risk for hypoglycemia?
- A. 9:00 AM
- B. 1:00 PM
- C. 11:00 AM
- D. 3:00 PM
Correct Answer: C
Rationale: This time is incorrect because regular insulin would peak after the teenager has eaten breakfast. This time is incorrect because it is after lunch when the NPH peaks. Regular insulin peaks in 2-3 hours and has a duration of 4-6 hours. NPH insulin's onset is 4-6 hours and peaks in 8-16 hours. Blood sugar would peak after meals and be lowest before meals and during the night. This time is incorrect because it is before the NPH and after the regular insulin peak times.