Nokea
A client is admitted with a diagnosis of myocardial infarction (MI). The client is complaining of chest pain. The nurse knows that pain related to an MI is due to
- A. Insufficient oxygenation of the cardiac muscle
- B. Potential circulatory overload
- C. Left ventricular overload
- D. Electrolyte imbalance
Correct Answer: A
Rationale: Insufficient oxygenation of the cardiac muscle. Due to ischemia of the heart muscle, the client experiences pain. This happens because an MI can block or interfere with the normal cardiac circulation.
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A client with a fractured hip asks the nurse about activity after discharge. The nurse should explain to the client that she should refrain from which of the following activities?
- A. Crossing her legs at the knee
- B. Sitting in a recliner
- C. Walking up stairs
- D. Carrying objects that weigh more than 10 pounds
Correct Answer: A
Rationale: Crossing legs at the knee can cause hip adduction, risking dislocation in a fractured hip. Other activities are generally safe with proper precautions.
The health care provider (HCP) explains the risks and benefits of a procedure to the client through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on the consent. The interpreter and client now have a lengthy discussion in the foreign language. The nurse should take which action at this time?
- A. Ask the interpreter to explain the discussion
- B. Confirm the client's consent with the interpreter, using gestures
- C. Have the interpreter witness the signature
- D. Indicate that the interpreter was used when witnessing the client's signature
Correct Answer: A
Rationale: Asking the interpreter to explain the discussion (A) ensures the nurse understands any concerns or clarifications, verifying informed consent. Gestures (B) are unreliable, the interpreter witnessing (C) is inappropriate, and noting interpreter use (D) is insufficient without understanding the discussion.
A nursing advocate is one who:
- A. makes decisions for others.
- B. encourages persons to make decisions for themselves and acts with or on behalf of the person to support those decisions.
- C. manages the care of others.
- D. is the legal representative for a person.
Correct Answer: B
Rationale: Nurse advocates work with clients to provide information and assistance is decision-making. The decisions and care that occur from these decisions are based on the right of the client to self-determination.
While admitting a client to an acute-care psychiatric unit, the nurse asks about substance abuse based on knowledge that:
- A. psychiatric illness is more prevalent in addicted populations.
- B. people with psychiatric disorders are more prone to substance abuse.
- C. substance disorders are easily detected and diagnosed in acute-care psychiatric settings.
- D. undetected substance problems have no real effect on treatment of psychiatric disorders.
Correct Answer: B
Rationale: The failure to address substance abuse among clients with psychiatric disorders interferes with treatment effectiveness and contributes to relapse. Misdiagnosis of a psychiatric disorder, suboptimal pharmacological treatment, neglect of appropriate interventions, or an inappropriate referral might also occur.
The nurse is caring for a pregnant woman with pregnancy induced hypertension (PIH) receiving magnesium sulfate intravenously. In assessing the client, it is noted that respirations are 12, pulse and blood pressure have dropped significantly, and 8 hour output is 200 ml. What should the nurse do first?
- A. Administer calcium gluconate
- B. Call the provider immediately
- C. Discontinue the magnesium sulfate
- D. Perform additional assessments
Correct Answer: C
Rationale: The assessments strongly suggest magnesium sulfate toxicity. The nurse must discontinue the IV immediately and take measures to ensure the safety of the client.