Nokea
A 27-year-old writer is admitted for the second time accompanied by his wife. He is demanding, arrogant, talks fast, and is hyperactive. Initially the nurse should plan this for a manic client:
- A. Set realistic limits to the client's behavior
- B. Repeat verbal instructions as often as needed
- C. Allow the client to express feelings to relieve tension
- D. Assign staff to be with the client at all times to help maintain control
Correct Answer: A
Rationale: For a manic client who is hyperactive and may engage in injurious activities, setting realistic limits to the client's behavior is crucial to ensure safety. A quiet environment with firm and consistent limits helps in managing the client's behavior effectively. While repeating verbal instructions can be helpful due to the client's distractibility, it is not the priority compared to setting limits for safety concerns. Allowing the client to express feelings is important, but it should be done through non-destructive methods. Assigning staff to be with the client at all times is not realistic or feasible in the clinical setting and does not address the core issue of managing the client's behavior and ensuring safety.
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Which of the following clients have barriers to accessing healthcare?
- A. A 36-year-old client who must use a wheelchair for mobility
- B. A 44-year-old client who is visiting the United States on a visa from India
- C. An 81-year-old client who is unable to drive
- D. All of the above
Correct Answer: D
Rationale: All of the provided clients have barriers to accessing healthcare. Clients with physical limitations, such as the 36-year-old client using a wheelchair, may face challenges in mobility and accessing healthcare facilities. The 44-year-old client from India visiting the United States on a visa may encounter barriers related to language, cultural differences, or insurance coverage. The 81-year-old client who is unable to drive may struggle with transportation to healthcare appointments. Therefore, all three clients face different barriers to accessing healthcare, making 'All of the above' the correct answer.
The family of a patient who is receiving therapeutic hypothermia states they do not understand why the patient is being kept so cold. What objective information can you provide to help address their concerns?
- A. Let them talk to another patient who has had the same therapy
- B. Provide research-based information about therapeutic hypothermia
- C. Connect them with the nurse manager
- D. Call the physician and ask him to talk to the family
Correct Answer: B
Rationale: Providing research-based information about the benefits of therapeutic hypothermia for their loved one will provide evidence that this is an established therapy with generally positive outcomes. Families are certainly not expected to be familiar with critical care interventions, and their concerns should be addressed with evidence-based data whenever possible. Option A is not appropriate as sharing patient information violates privacy laws and does not address the family's concerns directly. Option C may not directly provide the detailed information the family needs to understand therapeutic hypothermia. Option D involves unnecessary escalation by immediately involving the physician, when providing education and information should be the initial step in addressing the family's concerns.
A client with a new prescription for lithium carbonate for bipolar disorder is being educated by a nurse on early indications of toxicity. The nurse should include which of the following manifestations in the teachings?
- A. Constipation
- B. Polyuria
- C. Rash
- D. Tinnitus
Correct Answer: B
Rationale: Polyuria is a crucial early indication of lithium toxicity. It results from the drug's effect on the kidneys, leading to increased urine output. This is a significant symptom to monitor as it can indicate potential toxicity. Constipation, rash, and tinnitus are not typically associated with early indications of lithium toxicity. Constipation is more commonly seen as a side effect of some medications, while rash and tinnitus are not specific indicators of lithium toxicity.
You have noticed that the last several patients you have cared for have had questionable blood pressure readings from their arterial lines. When checked against cuff pressures, a discrepancy has been noted, and further investigation has revealed faulty transducers. This is not the first product issue with this company. What positive step could you take to help resolve this situation?
- A. Use the old stock from a previous company
- B. Verify the cuff pressures every hour to ensure accuracy
- C. Notify the risk manager
- D. Form a peer workgroup to evaluate new products
Correct Answer: D
Rationale: Forming a peer workgroup to evaluate new products would be an excellent opportunity for collaboration among peers, management, and the purchasing department. When clinicians are engaged to work toward solutions that address patient care issues, they experience more empowerment and control over their work environments.
Choice A is incorrect because using old stock from a previous company does not address the root cause of the faulty transducers from the current company. Choice B is incorrect as verifying cuff pressures every hour does not directly address the issue of faulty transducers. Choice C is less effective than forming a peer workgroup as it involves only notifying the risk manager without involving a collaborative effort to resolve the product issue.
What is the highest priority for post ECT care?
- A. Observe for confusion
- B. Monitor respiratory status
- C. Reorient to time, place, and person
- D. Document the client's response to the treatment
Correct Answer: B
Rationale: The highest priority for post ECT care is to monitor respiratory status. This is crucial because a life-threatening side effect of ECT is respiratory arrest. While observing for confusion and reorienting the client are important aspects of post ECT care, they are not as critical as ensuring the client's respiratory status is stable. Documenting the client's response to treatment is also important for maintaining accurate medical records, but it is not the highest priority immediately post ECT.