Nokea
A client in restraints is assigned to a newly graduated nurse. The nurse understands that which of the following are true regarding restraints? Select all that apply.
- A. Restraints can be chemical, mechanical, or physical.
- B. Children under 9 years of age have a 30-minute time limit in restraints.
- C. Bed rails are a form of restraint if used to prevent the client from leaving the bed.
- D. Restraints must be assessed every 2 hours for proper application and continued need.
- E. Once released, the client may be placed back in restraints for up to 24 hours if needed.
- F. Active listening, diversionary techniques, and reducing stimulation are alternatives to restraints.
Correct Answer: A, C, F
Rationale: Restraints include chemical, mechanical, or physical methods; bed rails are restraints if used to restrict movement; and non-restraint alternatives like active listening are preferred. Pediatric time limits and reassessment frequency vary by policy, and reapplication requires new orders.
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A client with a history of phenylketonuria (PKU) is seen in the local family planning clinic. While completing the intake history, the nurse provides information for a healthy pregnancy. Which statement indicates that the client needs further teaching?
- A. I can use use artificial sweeteners to keep me from gaining too much weight when I get pregnant.
- B. I need to go back on a low-phenylalanine diet before I get pregnant.
- C. Fresh fruits and raw vegetables will make good between-meal snacks for me.
- D. My baby could be mentally retarded if I don't stick to a diet eliminating phenylalanine.
Correct Answer: A
Rationale: Artificial sweeteners like aspartame contain phenylalanine, which is harmful in PKU, so the client's statement indicates a need for further teaching.
A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find:
- A. Decreased blood pressure
- B. Moist mucus membranes
- C. Decreased respirations
- D. Increased blood pressure
Correct Answer: A
Rationale: Sickle cell crisis with sequestration can lead to hypovolemia due to blood pooling in organs, resulting in decreased blood pressure.
A client receiving Parnate (tranylcypromine) is admitted in a hypertensive crisis. Which food is most likely to produce a hypertensive crisis when taken with the medication?
- A. Processed cheese
- B. Cottage cheese
- C. Cream cheese
- D. Cheddar cheese
Correct Answer: D
Rationale: Parnate, a monoamine oxidase inhibitor (MAOI), interacts with tyramine-rich foods like aged cheeses (e.g., cheddar) to cause hypertensive crisis due to increased norepinephrine release.
A pregnant client is keeping a 'kick count' log during the last trimester. Which of the following may indicate fetal distress?
- A. Fewer than 5 movements within 2 hours
- B. Fewer than 5 movements within 1 hour
- C. Fewer than 10 movements within 2 hours
- D. Fewer than 10 movements within 1 hour
Correct Answer: C
Rationale: Fewer than 10 movements in 2 hours (C) suggests fetal distress, as normal is >10 movements in 2 hours. Other options (A, B, D) set incorrect thresholds.
The nurse is caring for a client with B-Thalassemia major. Which therapy is used to treat Thalassemia?
- A. IV fluids
- B. Frequent blood transfusions
- C. Oxygen therapy
- D. Iron therapy
Correct Answer: B
Rationale: Frequent transfusions manage severe anemia in B-Thalassemia major.