Nokea
A client experienced a major burn over 55% of his body 36 hours ago. The client is restless and anxious, and states, 'I am in pain.' There is a physician prescription for intravenous morphine. The nurse's first action would be to:
- A. Administer the morphine
- B. Assess respirations
- C. Assess urine output
- D. Check serum potassium levels
Correct Answer: B
Rationale: Assessing respirations is critical before administering morphine, as opioids can cause respiratory depression, especially in a burn client with potential airway compromise.
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The nurse is assisting in the assessment of the patient admitted with 'extreme abdominal pain.' The nurse asks the client about the medication that he has been taking because:
- A. Interactions between medications will cause abdominal pain.
- B. Various medications taken by mouth can affect the alimentary tract.
- C. This will provide an opportunity to educate the patient regarding the medications used.
- D. The types of medications might be attributable to an abdominal pathology not already identified.
Correct Answer: D
Rationale: Medications can cause or exacerbate abdominal pathology, making it essential to assess their role in the patient's symptoms.
The nurse recognizes which of the following as the priority nursing diagnosis for the client in thyroid crisis?
- A. Risk for ineffective breathing pattern
- B. Risk for imbalanced body temperature
- C. Risk for decreased cerebral tissue perfusion
- D. Activity intolerance
Correct Answer: B
Rationale: Thyroid crisis (thyroid storm) causes hyperthermia, making imbalanced body temperature the priority due to the risk of life-threatening hypermetabolic complications.
The nurse is caring for the patient following removal of a large posterior oral lesion. The priority nursing measure would be to:
- A. Maintain a patent airway
- B. Perform meticulous oral care every 2 hours
- C. Ensure that the incisional area is kept as dry as possible
- D. Assess the client frequently for pain
Correct Answer: A
Rationale: Maintaining a patent airway is critical post-oral surgery due to the risk of swelling or bleeding obstructing the airway.
The nurse is assigned to work with the parents of a retarded child. Which of the following should the nurse include in the care plan for the parents?
- A. Interpret the grieving process for the parents.
- B. Discuss the reality of institutional placement.
- C. Assist the parents in making decisions and long-term plans for the child.
- D. Perform a family assessment to assist in the planning of intervention.
Correct Answer: D
Rationale: assessment, this will help the nurse to know where the family is in regard to grieving, coping, etc.
The nurse is caring for a client admitted with suspected myasthenia gravis. Which finding is usually associated with a diagnosis of myasthenia gravis?
- A. Visual disturbances, including diplopia
- B. Ascending paralysis and loss of motor function
- C. Cogwheel rigidity and loss of coordination
- D. Progressive weakness that is worse at the day's end
Correct Answer: D
Rationale: Myasthenia gravis is characterized by muscle weakness that worsens with activity and improves with rest, typically more pronounced at the end of the day.