Nokea
A 59-year-old male client is brought to the emergency room where he is assessed to have a Glasgow Coma Scale of 3. Based on this assessment, how should the nurse characterize the client's condition?
- A. The client is experiencing increased intracranial pressure
- B. He has a good prognosis for recovery
- C. This client is conscious, but is not oriented to time and place
- D. He is in a coma, and has a very poor prognosis
Correct Answer: D
Rationale: The correct answer is D because a Glasgow Coma Scale score of 3 indicates deep unconsciousness, which is classified as a coma. A GCS score of 3 signifies the lowest possible level of consciousness and is associated with a very poor prognosis due to the severity of neurological impairment. Choices A, B, and C are incorrect. Increased intracranial pressure may be present in comatose patients but is not solely indicated by a GCS score of 3. A good prognosis is unlikely with a GCS score of 3. Being unconscious with a GCS score of 3 does not equate to being conscious but disoriented as in choice C.
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A client is taught how to collect a 24-hour urine specimen. Which statement indicates understanding of the procedure?
- A. I should keep the urine specimen refrigerated.
- B. I need to start the collection in the morning after my first void.
- C. I will collect the urine for 24 hours and keep it on ice.
- D. I will start collecting the urine after discarding my first morning specimen.
Correct Answer: D
Rationale: The correct answer is D because discarding the first morning specimen ensures accurate collection starts. Choice A is incorrect because refrigeration is unnecessary for a 24-hour urine collection. Choice B is incorrect as the first void should be included. Choice C is incorrect as there's no need to keep the urine on ice.
The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit?
- A. A 45-year-old with chronic hepatitis B.
- B. A 35-year-old with lupus erythematosus
- C. A 19-year-old diagnosed with rubella
- D. A 25-year-old with herpes lesions of the vulva
Correct Answer: B
Rationale: The correct answer is B: A 35-year-old with lupus erythematosus. This client should be recommended for transfer to the antepartal unit because lupus erythematosus is an autoimmune disorder that can affect pregnancy outcomes. The antepartal unit is better equipped to provide specialized care for high-risk pregnancies, which would be necessary for a client with lupus.
A: A 45-year-old with chronic hepatitis B - Hepatitis B does not directly impact pregnancy outcomes and does not require transfer to the antepartal unit.
C: A 19-year-old diagnosed with rubella - Rubella is a viral infection that can be harmful during pregnancy, but the client should be managed in a different unit specialized in infectious diseases.
D: A 25-year-old with herpes lesions of the vulva - Herpes lesions of the vulva can be managed in the medical-surgical unit and do not necessarily require transfer to the antepartal unit unless there
A client with a history of seizures is being discharged with a prescription for phenytoin (Dilantin). Which instruction should the nurse provide this client?
- A. Take the medication with meals
- B. Avoid alcohol while taking this medication
- C. Limit sodium intake
- D. Take the medication at bedtime
Correct Answer: B
Rationale: The correct answer is B: Avoid alcohol while taking this medication. Phenytoin interacts with alcohol, increasing the risk of side effects such as dizziness and drowsiness. Alcohol can also reduce the effectiveness of the medication. Taking the medication with meals (choice A) may help reduce gastrointestinal upset but does not address the alcohol interaction. Limiting sodium intake (choice C) is not directly related to phenytoin therapy. Taking the medication at bedtime (choice D) is not necessary for all clients and does not address the alcohol interaction.
An experienced nurse tells the nurse-manager that working with a new graduate is impossible because the new graduate will not listen to suggestions. The new graduate comes to the nurse-manager describing the senior nurse's attitude as challenging and offensive. What action is best for the nurse manager to take?
- A. Have both nurses meet separately with the staff mental health consultant
- B. Listen actively to both nurses and offer suggestions to solve the dilemma
- C. Ask the senior nurse to examine mentoring strategies used with the new graduate
- D. Ask the nurses to meet with the nurse-manager to identify ways of working together
Correct Answer: D
Rationale: The correct answer is D. The nurse-manager should ask the nurses to meet to identify ways of working together. This is the best action because it promotes open communication, collaboration, and conflict resolution between the two nurses. By facilitating a discussion between them, the nurse-manager can help address the underlying issues, clarify misunderstandings, and find common ground for effective teamwork. This approach encourages mutual understanding and fosters a positive working relationship.
A: Having both nurses meet separately with the staff mental health consultant does not directly address the conflict between them.
B: While listening actively and offering suggestions is important, involving both nurses in the discussion is crucial for resolving the conflict.
C: Asking the senior nurse to examine mentoring strategies does not involve the new graduate in the conversation and may not address the overall issue.
The nurse is administering total parenteral nutrition (TPN) via a central line at 75 ml/hour to a client who had a bowel resection 4 days ago. Which laboratory finding requires the most immediate intervention by the nurse?
- A. Blood glucose of 140 mg/dL
- B. White blood cell count of 8000/mm³
- C. Serum potassium of 3.8 mEq/L
- D. Serum calcium of 7.8 mg/dL
Correct Answer: D
Rationale: The correct answer is D: Serum calcium of 7.8 mg/dL. This finding indicates hypocalcemia, which can lead to life-threatening cardiac arrhythmias. Low calcium levels can be caused by TPN administration or poor calcium absorption following bowel resection. Immediate intervention may include administering IV calcium gluconate.
A: Blood glucose of 140 mg/dL is within the normal range and not an immediate concern.
B: White blood cell count of 8000/mm³ is within the normal range and does not require immediate intervention.
C: Serum potassium of 3.8 mEq/L is within the normal range and does not pose an immediate threat.