Nokea
A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The nurse should be most careful to monitor the client for which dysrhythmia during this procedure?
- A. Bradycardia
- B. Tachycardia
- C. Premature ventricular beats
- D. Heart block
Correct Answer: A
Rationale: During suctioning, a vagal response can be triggered leading to bradycardia. It is crucial for the nurse to monitor for this potential dysrhythmia. Tachycardia (Choice B) is less likely during suctioning and is not the priority. Premature ventricular beats (Choice C) and heart block (Choice D) can occur but are less common compared to bradycardia in this situation.
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A client with cancer is to undergo an intravenous pyelogram. The nurse should:
- A. Ensure adequate fluid intake 24 hours before the procedure
- B. Ask the client to void immediately before the study
- C. Administer medication that affects the central nervous system as prescribed
- D. Position the client appropriately for the procedure
Correct Answer: B
Rationale: The correct answer is to ask the client to void immediately before the study. For an intravenous pyelogram, the client may have orders for laxatives or enemas, so ensuring the client voids before the test is important to prevent obscuring visualization of the kidney, ureters, and bladder. Choice A is incorrect because there is no need to force fluids before the procedure. Choice C is incorrect as medications affecting the central nervous system should not be held unless specified by the healthcare provider. Choice D is incorrect as covering the reproductive organs with an x-ray shield is not necessary for an intravenous pyelogram.
The nursing assistant hitting the client in the long-term care facility can be charged with:
- A. Negligence
- B. Tort
- C. Assault
- D. Malpractice
Correct Answer: C
Rationale: Assault is the appropriate charge in this scenario. Assault involves physically striking or touching someone inappropriately. Negligence (Choice A) refers to failing to provide proper care for the client. Tort (Choice B) is a wrongful act committed against the client or their property. Malpractice (Choice D) is the failure to perform an act that should have been done or the improper performance of an act resulting in harm to the client. Since the nursing assistant physically struck the client, the charge of assault is most fitting.
The nurse wishes to decrease a client's use of denial and increase the client's expression of feelings. To do this, the nurse should:
- A. tell the client to stop using the defense mechanism of denial.
- B. positively reinforce each expression of feelings.
- C. instruct the client to express feelings.
- D. challenge the client each time denial is used.
Correct Answer: B
Rationale: In the scenario provided, the nurse aims to reduce the client's use of denial and encourage the expression of feelings. Positive reinforcement for each expression of feelings is an effective approach to achieve this goal. By positively reinforcing the client's expression of feelings, the nurse encourages the desired behavior, making it more likely for the client to continue sharing their emotions. This approach creates a supportive and accepting environment for the client. In contrast, telling the client to stop using denial (Choice A) may create resistance and inhibit communication by putting pressure on the client. Instructing the client to express feelings (Choice C) is less effective as it lacks the element of reinforcement that is essential for behavior modification. Challenging the client each time denial is used (Choice D) may lead to defensiveness and hinder the therapeutic relationship, making it a less favorable option.
The client is being assessed for possible pernicious anemia. Which finding would support this diagnosis?
- A. A weight loss of 10 pounds in 2 weeks
- B. Complaints of numbness and tingling in the extremities
- C. A red, beefy tongue
- D. A hemoglobin level of 12.0 g/dL
Correct Answer: C
Rationale: The correct answer is a red, beefy tongue, which is characteristic of pernicious anemia due to the atrophy of the papillae on the tongue. This finding is known as glossitis. A red, beefy tongue is a classic sign of pernicious anemia. Choice A, weight loss of 10 pounds in 2 weeks, is non-specific and not a typical finding in pernicious anemia. Choice B, complaints of numbness and tingling in the extremities, are more indicative of peripheral neuropathy, a common symptom of vitamin B12 deficiency, which can be seen in pernicious anemia. Choice D, a hemoglobin level of 12.0 g/dL, falls within the normal range and does not specifically point towards pernicious anemia, which is characterized by low hemoglobin levels due to impaired absorption of vitamin B12.
In a brief treatment program, what is a realistic short-term goal for a client who was raped?
- A. Identify all psychosocial problems
- B. Eliminate the client's enticing behaviors
- C. Resolve feelings of trauma and fear
- D. Verbalize feelings about the event
Correct Answer: D
Rationale: A realistic short-term goal for a client who was raped and is receiving a brief treatment program is for the client to verbalize feelings about the event. This goal focuses on helping the client express their emotions, which can be a crucial step in the healing process. Options A and C are incorrect because a brief treatment program is not typically aimed at identifying or resolving all psychosocial problems or deep-rooted trauma and fear. Option B is also incorrect as the goal is to support the client in processing their feelings rather than focusing on behaviors.