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A client has just finished her lunch, consisting of shrimp with rice, fruit salad, and a roll. The client calls for the nurse, stating, 'My throat feels thick and I'm having trouble breathing.' What action should the nurse implement first?
- A. Place the bed in Trendelenburg position and call the physician
- B. Take the client's vital signs and administer Benadryl 50 mg PO
- C. Place the bed in high Fowler's position and call the physician
- D. Start an Aminophylline drip and call the physician
Correct Answer: C
Rationale: Symptoms suggest an allergic reaction, possibly anaphylaxis from shrimp. Placing the client in high Fowler's position facilitates breathing, and calling the physician ensures rapid intervention.
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A client has had 4 pregnancies. She experienced one miscarriage at 12 weeks, had one stillborn birth at 34 weeks, a healthy son at 38 weeks, and a healthy daughter at 40 weeks. How would the client's obstetric history be classified?
- A. Gravida 3, Para 2
- B. Gravida 4, Para 4
- C. Gravida 4, Para 3
- D. Gravida 4, Para 2
Correct Answer: D
Rationale: Gravida 4 (4 pregnancies), Para 2 (2 viable births at 38 and 40 weeks). Miscarriage and stillbirth count as pregnancies but not viable births.
A nursing instructor is preparing a lesson on the dangers of using drugs and alcohol during pregnancy. She would include which of the following as a primary disability associated with children diagnosed with fetal alcohol syndrome?
- A. poor motor skills
- B. promiscuous behavior
- C. future drug and alcohol dependency
- D. diagnosis of clinical depression
Correct Answer: A
Rationale: Fetal alcohol syndrome causes primary disabilities like poor motor skills due to neurological damage. Promiscuity, dependency, and depression are not primary effects.
A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:
- A. Decreased blood pressure and constricted pupils
- B. Increased heart rate and increased respirations
- C. Increased respirations and increased blood pressure
- D. Anoxia and absence of the cough reflex
Correct Answer: A
Rationale: Cholinergic crisis, due to excessive acetylcholinesterase inhibitors, causes symptoms like constricted pupils and decreased blood pressure from parasympathetic overstimulation.
A client is receiving a blood transfusion following surgery. In the event of a transfusion reaction, any unused blood should be:
- A. Sealed and discarded in a red bag
- B. Flushed down the client's commode
- C. Sealed and discarded in the sharp's container
- D. Returned to the blood bank
Correct Answer: D
Rationale: Unused blood must be returned to the blood bank for analysis in case of a transfusion reaction.
A school nurse is approached by a student who says that her friend has been cutting herself on the arms. The student asks the nurse not to tell anyone. Which response by the nurse is correct?
- A. I have to notify her parents, because this affects her personal safety.
- B. I won't tell anyone, but let me know if she starts talking about suicide.
- C. I will call the hospital and let them send a psychiatrist to do an evaluation on your friend.
- D. I will make it a point to run into her in the hall and notice the cuts on her arms so I can ask about them.
Correct Answer: A
Rationale: Self-harm indicates a safety risk, requiring parental notification to ensure the student receives appropriate intervention.