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A client demonstrating unstable ventricular tachycardia (VT) loses consciousness and becomes pulseless after an initial treatment with a dose of lidocaine intravenously. Which item should the nurse caring for the client immediately obtain?
- A. A pacemaker
- B. A defibrillator
- C. A second dose of lidocaine
- D. An electrocardiogram machine
Correct Answer: B
Rationale: For the client with VT who becomes pulseless, the primary health care provider or qualified advanced cardiac life support personnel immediately defibrillate the client. In the absence of this equipment, cardiopulmonary resuscitation is initiated immediately. None of the remaining options are items that are needed immediately to manage this situation.
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Which of the following is NOT an essential component of a restraint order?
- A. Informed consent for the restraint
- B. The reason for the restraint
- C. The type of restraint to be used
- D. Client behaviors that necessitated the restraints
Correct Answer: A
Rationale: A restraint order requires the reason , type , and client behaviors necessitating the restraint . Informed consent is not typically required for restraints, as they are used in emergencies or for safety.
The nurse is assessing a client with suspected meningitis. Which finding is most concerning?
- A. Fever of 101°F.
- B. Neck stiffness.
- C. Mild headache.
- D. Fatigue.
Correct Answer: B
Rationale: Neck stiffness is a hallmark sign of meningitis, indicating meningeal irritation and requiring urgent evaluation.
The nurse is preparing a teaching plan for a 45-year-old client recently diagnosed with type 2 diabetes mellitus. What is the first step in this process?
- A. Establish goals.
- B. Assess the client's learning needs.
- C. Set priorities of learning needs.
- D. Select teaching strategies.
Correct Answer: B
Rationale: Assessing the client's learning needs is the first step to tailor education to their knowledge level, preferences, and barriers, ensuring effective teaching.
The nurse recognizes that a client with pain disorder is improving when the client says which of the following?
- A. I need to have a good cry about all the pain I've been in and then not dwell on it.'
- B. I need to find another physician who can accurately diagnose my condition.'
- C. The pain medicine that you gave me helps me to relax.'
- D. I'm angry with all of the doctors I've seen who don't know what they're doing.'
Correct Answer: A
Rationale: Expressing a desire to process emotions and move forward indicates improved coping, a sign of progress in managing pain disorder.
A client with a history of epilepsy is prescribed phenobarbital. The nurse should monitor the client for which of the following side effects?
- A. Drowsiness.
- B. Hypertension.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: A
Rationale: Phenobarbital commonly causes drowsiness, which the nurse should monitor in clients with epilepsy.