Nokea
A client hospitalized with mania is racing wildly about the unit trying to organize the other clients into a game of Ping-Pong. The nurse should:
- A. Send the client to the recreation room for art therapy.
- B. Take the client outside for a walk.
- C. Allow the client to continue because his activities are goal directed.
- D. Suggest that the client do exercises to a video instead.
Correct Answer: B
Rationale: Taking the client for a walk redirects energy safely and reduces stimulation. Art therapy may not engage, continuing the activity risks escalation, and video exercises lack supervision.
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A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted?
- A. Improvement in short-term memory
- B. Improvement in spontaneous activity
- C. Reduction in number of visual hallucinations
- D. Reduction of dizziness with standing
Correct Answer: B
Rationale: Carbidopa-levodopa treats Parkinson's symptoms like bradykinesia, improving spontaneous activity, which is the primary therapeutic goal.
The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to
- A. Excessive fetal weight
- B. Low blood sugar levels
- C. Depletion of subcutaneous fat
- D. Progressive placental insufficiency
Correct Answer: D
Rationale: The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be related to hypoxia.
The nurse has assigned a nursing assistant to give the client a bath. Which observation reported by the nursing assistant requires immediate attention by the nurse?
- A. A red area on the back that disappears after it is massaged
- B. A red area on the hip that does not go away after the area is massaged
- C. The client's insistence on doing most of the bath
- D. The indwelling urethral catheter is draining clear, amber urine.
Correct Answer: B
Rationale: A non-blanching red area on the hip suggests a pressure injury, requiring immediate nursing intervention to prevent progression.
The nurse is reviewing teaching about newly prescribed clonazepam with a client who is receiving palliative care for cancer. Which client statement shows a correct understanding of the nurse's teaching?
- A. I am glad that I can continue to take my kava supplement each morning.
- B. If I can't sleep, I will take some melatonin with my evening dose of clonazepam.
- C. If I feel restless, I can put some drops of lavender essential oil in a diffuser to calm myself.
- D. When my anxiety is getting really intense, I will drink some valerian tea to help me relax.
Correct Answer: C
Rationale: Lavender essential oil in a diffuser is a safe, non-pharmacological method to reduce restlessness, compatible with clonazepam without risk of interaction.
A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action?
- A. Ask the client if there are any breathing problems
- B. Have the client void as much as possible
- C. Check the vital signs
- D. Auscultate the lungs
Correct Answer: D
Rationale: All of the options would be part of the evaluation for the effects of the large amount of fluid in a short period of time. However, the worst result is heart failure with lung congestion, so the auscultation of the lungs is the priority action.