Nokea
A client has developed a vitamin C deficiency. Which of the following symptoms might the nurse most likely see with this condition?
- A. Cracks at the corners of the mouth
- B. Altered mental status
- C. Bleeding gums and loose teeth
- D. Anorexia and diarrhea
Correct Answer: C
Rationale: A client with a severe vitamin C deficiency has a condition called scurvy. Scurvy is characterized by symptoms such as bleeding gums, loose teeth, poor wound healing, and easy bruising. The correct answer is 'Bleeding gums and loose teeth' because these are classic signs of scurvy due to vitamin C deficiency. Choice A ('Cracks at the corners of the mouth') is more indicative of a deficiency in B vitamins, specifically riboflavin. Choice B ('Altered mental status') is not typically associated with vitamin C deficiency but can occur with other conditions like vitamin B12 deficiency. Choice D ('Anorexia and diarrhea') are not common symptoms of vitamin C deficiency, as they are more commonly associated with other gastrointestinal issues or deficiencies in different nutrients.
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After an endoscopic procedure with general anesthesia, what is a priority nursing consideration for a patient in the day surgery center?
- A. Raise the siderails of the patient's bed
- B. Do not offer fluids, food, or any oral intake
- C. Check the temperature of the patient
- D. Teach the patient to avoid aspirin or NSAIDS
Correct Answer: B
Rationale: After an endoscopic procedure with general anesthesia, the priority nursing consideration is to not offer fluids, food, or any oral intake to the patient. Endoscopies involve passing a tube through the mouth into the esophagus or upper GI. Anesthesia is often given to inactivate the gag reflex, making the patient vulnerable to aspiration. Raising the siderails of the patient's bed is important for safety but not the immediate priority. Checking the patient's temperature may be important but is not the priority immediately after the procedure. Teaching the patient to avoid aspirin or NSAIDS is important for post-procedure care but is not the priority immediately after the endoscopic procedure.
Which response would best assist the chemically impaired client in dealing with issues of guilt?
- A. Addiction usually causes people to feel guilty. Don't worry, it is a typical response due to your drinking behavior.
- B. What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?
- C. Don't focus on your guilty feelings. These feelings will only lead you to drinking and taking drugs.
- D. You've caused a great deal of pain to your family and close friends, so it will take time to undo all the things you've done.
Correct Answer: B
Rationale: The correct response is, 'What have you done that you feel most guilty about and what steps can you begin to take to help you lessen this guilt?' This response encourages the client to reflect on their actions, identify sources of guilt, and develop a plan to address and reduce these feelings constructively. Choice A is incorrect as it dismisses the client's guilt as typical, potentially invalidating their emotions. Choice C is incorrect as it suggests avoiding guilty feelings by turning to substance use, which is counterproductive. Choice D is incorrect as it focuses on the negative consequences of the client's actions without offering a constructive way to address and alleviate guilt.
A patient in the emergency room has a fractured left elbow and presents with an unequal radial pulse, swelling, and numbness in the left hand after waiting for 5 hours. What is the nurse's priority intervention?
- A. Place the patient in a supine position
- B. Ask the patient to rate his pain on a scale of 1 to 10.
- C. Wrap the fractured area with a snug dressing
- D. Start an IV in the other arm.
Correct Answer: D
Rationale: The correct answer is to start an IV in the other arm. In this scenario, the patient is showing signs of Acute Compartment Syndrome, a serious condition that occurs due to increased pressure within a muscle compartment, leading to decreased blood flow and potential tissue damage. Starting an IV is crucial as the patient may require emergency surgery, such as a fasciotomy, to relieve the pressure and prevent further complications. Placing the patient in a supine position, asking about pain levels, or wrapping the fractured area, though important, are not the priority interventions in this critical situation where immediate medical intervention is necessary to prevent irreversible damage or loss of limb.
A patient asks the nurse whether he is a good candidate to use a CPAP machine. The nurse reviews the client's history. Which condition would contraindicate the use of a CPAP machine?
- A. The patient is in the late stage of dementia.
- B. The patient has a history of bronchitis.
- C. The patient has had suicidal gestures/attempts in the past.
- D. The patient is on beta-blockers.
Correct Answer: A
Rationale: The correct answer is that the patient is in the late stage of dementia. In late-stage dementia, individuals may have an inability to follow commands and understand instructions independently, which are essential for proper installation and use of a CPAP machine. This makes using a CPAP machine challenging and potentially ineffective for patients in this condition.
Choice B, having a history of bronchitis, does not contraindicate the use of a CPAP machine. In fact, CPAP therapy can be beneficial for patients with respiratory conditions like bronchitis.
Choice C, a history of suicidal gestures/attempts, while concerning for the patient's mental health, does not directly contraindicate the use of a CPAP machine.
Choice D, being on beta-blockers, is not a contraindication for CPAP machine use. Beta-blockers are commonly used medications for various conditions and do not interfere with the use of a CPAP machine.
A client using an intraaural hearing aid experiences whistling after placement. What is the nurse's next action?
- A. Try to reposition the hearing aid
- B. Change the batteries
- C. Remove the device and have it cleaned
- D. Notify the physician that the hearing aid is not working
Correct Answer: A
Rationale: An intraaural hearing aid, also known as an in-the-ear hearing aid, is placed in the ear canal. Whistling after placement indicates improper positioning of the device. The correct action for the nurse is to try repositioning the hearing aid to eliminate the whistling. Changing the batteries is not necessary for addressing whistling. Removing the device to clean it is not the immediate action needed for whistling. Notifying the physician is premature without attempting to reposition the hearing aid first.