Nokea
A client admitted with hepatic encephalopathy continues to attempt ambulation without assistance despite repeated instruction. Which intervention should the nurse take to promote safety?
- A. administer Xanax 6 mg PO
- B. apply a vest restraint device
- C. request a family member stay with the client around the clock
- D. move the client closer to the nurses' station
Correct Answer: D
Rationale: Moving the client closer to the nurses’ station allows frequent monitoring, promoting safety without restraints or sedation, which are less appropriate.
You may also like to solve these questions
Which of the following statements best explains the rationale for placing the client in Trendelenburg position during the insertion of a central line catheter?
- A. It will facilitate catheter insertion.
- B. It will make the client more comfortable during the insertion.
- C. It will prevent the occurrence of ventricular tachycardia.
- D. It will prevent the development of pulmonary emboli.
Correct Answer: A
Rationale: The Trendelenburg position increases venous filling in the upper body, making the subclavian or jugular veins easier to access for catheter insertion.
A 46-year-old male has been placed under therapeutic hypothermic care after a myocardial infarction (MI). The nurse correctly explains to the family,
- A. Therapeutic hypothermia increases the production of neurotransmitters in the brain.'
- B. Therapeutic hypothermia will repair damaged cardiac tissue.'
- C. Therapeutic hypothermia will help protect the brain from injury by slowing metabolism.'
- D. Therapeutic hypothermia will slow the heart rate to reduce likelihood of another MI.'
Correct Answer: C
Rationale: Therapeutic hypothermia post-MI slows metabolism, reducing cerebral oxygen demand and protecting the brain from ischemic injury.
During a pre-op assessment, the nurse would chart which finding(s) as subjective data? Select all that apply.
- A. The client is sweating and wringing his hands.
- B. The client states, 'I am having second thoughts about my surgery.'
- C. The client reports he has lost 6 pounds in the last 2 months.
- D. The client's blood pressure is 128/82.
- E. The client rates his pain as a 3 on a scale of 0-10.
Correct Answer: B,C,E
Rationale: Subjective data are client-reported, including statements about surgery concerns, weight loss, and pain ratings. Sweating/wringing hands and blood pressure are objective (observable/measurable).
The nurse is preparing to walk the postpartum client for the first time since delivery. Before walking the client, the nurse should:
- A. Give the client pain medication
- B. Assist the client in dangling her legs
- C. Have the client breathe deeply
- D. Provide the client additional fluids
Correct Answer: B
Rationale: Dangling the legs before walking helps assess for orthostatic hypotension and ensures the client is stable, reducing the risk of fainting.
A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
- A. High fever
- B. Nonproductive cough
- C. Rhinitis
- D. Vomiting and diarrhea
Correct Answer: A
Rationale: High fever is a hallmark of bacterial pneumonia due to the body's response to infection.