Nokea
A client is experiencing symptoms of early alcohol withdrawal. The client's blood pressure is 150/85 mm Hg and the pulse is 98 bpm. The nurse should:
- A. Administer lorazepam (Ativan).
- B. Apply arm and leg restraints.
- C. Assign an unlicensed assistive personnel to sit with the client.
- D. Notify the physician.
Correct Answer: D
Rationale: Notifying the physician is the priority to obtain orders for managing alcohol withdrawal symptoms, which may require medications like lorazepam.
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A 3-year-old is admitted with croup. Which intervention should the nurse prioritize?
- A. Administer racemic epinephrine
- B. Provide a high-calorie diet
- C. Encourage oral fluids
- D. Apply a warm compress to the throat
Correct Answer: A
Rationale: Racemic epinephrine is the priority for croup to reduce airway swelling and relieve stridor, addressing the immediate respiratory distress.
The nurse is caring for a client with a spinal cord injury at the T4 level. Which of the following findings indicates autonomic dysreflexia?
- A. Bradycardia and hypertension.
- B. Tachycardia and hypotension.
- C. Fever and chills.
- D. Hypoxia and cyanosis.
Correct Answer: A
Rationale: Autonomic dysreflexia presents with bradycardia and hypertension due to unopposed sympathetic stimulation below the injury level.
A hospitalized client fell on the floor and sustained a small laceration on her hand that required stitches. The intern will suture the client's hand at the client's bedside and asks for bupivacaine (Marcaine) with epinephrine and a suture kit in order to suture the laceration. The nurse should question which of the following?
- A. The intern's ability to suture.
- B. The client's room as an aseptic environment.
- C. Marcaine with epinephrine as the local anesthetic.
- D. The cosmetic effect from not having a plastic surgeon do the suturing.
Correct Answer: C
Rationale: Bupivacaine with epinephrine should be questioned for hand lacerations, as epinephrine can cause vasoconstriction and potential tissue ischemia in extremities.
As the nurse in a primary care clinic, which cultural concern would you integrate into your psychological assessments of your clients?
- A. The concern related to the client's cultural reluctance to report psychological symptoms because of some possible culturally based stigma associated with psychiatric mental health disorders
- B. Concerns revolving around the lack of financial and health insurance resources to pay for psychological care
- C. Concerns related to the compliance with psychological treatment regimens because of the client's lack of social support systems
- D. The concern related to the culturally based client apathy about nursing care and nursing assessments
Correct Answer: A
Rationale: Cultural stigma around mental health can significantly impact clients' willingness to report psychological symptoms, making it a critical consideration in assessments.
A client with cirrhosis reports itching. Which intervention should the nurse implement?
- A. Apply a heating pad.
- B. Administer an antihistamine.
- C. Encourage a hot shower.
- D. Apply a moisturizing lotion.
Correct Answer: D
Rationale: Moisturizing lotion relieves itching in cirrhosis by hydrating dry skin without exacerbating symptoms.