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A charge, nurse is teaching new staff members about factors that increase a client's risk to become violent: Which of the following risk factors should the nurse include as the best predictor of future violence?
- A. A history of being in prison
- B. Male gender
- C. Experiencing delusions
- D. Previous violent behavior
Correct Answer: D
Rationale: The correct answer is D: Previous violent behavior. This is the best predictor of future violence because past behavior is a strong indicator of future actions. Individuals who have a history of violent behavior are more likely to engage in violent acts again. Choice A (A history of being in prison) is not as strong of a predictor as it does not specifically address violent behavior. Choice B (Male gender) is a generalization and not always indicative of violent behavior. Choice C (Experiencing delusions) may increase the risk of violence but does not directly predict future violent behavior as strongly as previous violent actions do.
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After puncturing the skin with the vascular access device and noting a blood return in the flashback chamber, which of the following actions should the nurse perform next?
- A. Flush the catheter with saline
- B. Retract the stylet
- C. Advance the catheter into the vein
- D. Release the tourniquet
Correct Answer: C
Rationale: The correct answer is C: Advance the catheter into the vein. After confirming blood return in the flashback chamber, advancing the catheter ensures proper placement within the vein for medication delivery. Retracting the stylet (B) prematurely can displace the catheter. Flushing with saline (A) before confirming placement is risky. Releasing the tourniquet (D) is done after securing catheter placement.
Which of the following actions should the nurse include in the plan of care?
- A. Increase the amount of refined grains in the client's diet
- B. Provide the client with a cold drink prior to defecation
- C. Administer a cathartic suppository 30 min prior to scheduled defecation times
- D. Encourage a maximum fluid intake of 1,500 mL per day
Correct Answer: C
Rationale: The correct answer is C: Administer a cathartic suppository 30 min prior to scheduled defecation times. This action helps stimulate bowel movement by inducing peristalsis, making defecation easier for the client. Increasing refined grains (A) may worsen constipation due to their low fiber content. Providing a cold drink (B) may have a minimal effect on bowel movements. Encouraging a maximum fluid intake of 1,500 mL per day (D) is important for hydration but may not directly address constipation.
Which of the following information should the nurse plan to include in the teaching?
- A. Apply petroleum jelly to soothe the mucous membranes
- B. Use synthetic fabrics for the client’s bedding
- C. Clean the equipment with an alcohol-based cleaning product.
- D. Avoid using nail polish remover around the client.
Correct Answer: D
Rationale: The correct answer is D: Avoid using nail polish remover around the client. This is important because nail polish remover contains harsh chemicals that can be harmful if inhaled or absorbed through the skin, especially for clients with compromised health conditions. Applying petroleum jelly (choice A) may not be recommended as it can trap bacteria and cause infection. Using synthetic fabrics for bedding (choice B) may not be ideal as natural fibers are more breathable and comfortable. Cleaning equipment with alcohol-based products (choice C) may not be suitable as it can be irritating to sensitive skin. Therefore, choice D is the best option for the client's safety and well-being.
A nurse is caring for an infant who has gastroenteritis. Which of the following assessment findings should the nurse report to the provider?
- A. Pale arid a 24 hr fluid deficit of 30 ml
- B. Sunken fontanels and dry mucous membranes
- C. Decreased appetite and irritability
- D. Temperature 38° C(100.4° Fl and pulse rate 124/min
Correct Answer: B
Rationale: The correct answer is B: Sunken fontanels and dry mucous membranes. These findings indicate severe dehydration in the infant, which is a critical condition that requires immediate intervention. Sunken fontanels suggest significant fluid loss, while dry mucous membranes are indicative of dehydration. Reporting these findings to the provider is crucial for prompt treatment to prevent further complications.
Incorrect Answer A: Pale and a 24 hr fluid deficit of 30 ml. Pale skin alone may not indicate severe dehydration, and a 24-hour fluid deficit of 30 ml is relatively small and not alarming.
Incorrect Answer C: Decreased appetite and irritability. These are common symptoms of gastroenteritis and may not necessarily indicate a need for immediate reporting to the provider.
Incorrect Answer D: Temperature 38° C and pulse rate 124/min. These vital signs are elevated but do not directly indicate severe dehydration requiring immediate reporting.
For which of the following therapeutic effects should the nurse monitor the client?
- A. Deep tendon reflexes 2+
- B. Pulse rate 100/min
- C. Urine output 20 mL/hr
- D. 1+ proteinuria via urine dipstick
Correct Answer: A
Rationale: The correct answer is A: Deep tendon reflexes 2+. Monitoring deep tendon reflexes is essential in assessing neurological function and detecting abnormalities such as hyperreflexia or hyporeflexia. A normal response of 2+ indicates intact neurological pathways. Abnormal reflexes could be indicative of various neurological conditions. Pulse rate, urine output, and proteinuria are important parameters to monitor but are not specifically related to therapeutic effects. Monitoring deep tendon reflexes is crucial for detecting early signs of neurological complications and guiding appropriate interventions.