Nokea
A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, 'The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart.' The nurse's best response is:
- A. I know you're feeling frightened right now, but I want you to know that I don't see anyone in the corner.'
- B. You'll probably see strange things for a while until the PCP wears off.'
- C. Try to sleep. When you wake up, the devil will be gone.'
- D. You're probably feeling guilty because you used illegal drugs tonight.'
Correct Answer: A
Rationale: The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and reinforcing reality.
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A client is admitted to the emergency room with a gunshot wound to the right arm. After dressing the wound and administering the prescribed antibiotic, the nurse should:
- A. Ask the client if he has any medication allergies.
- B. Check the client's immunization record.
- C. Apply a splint to immobilize the arm.
- D. Administer medication for pain.
Correct Answer: C
Rationale: Immobilizing the arm with a splint is critical to prevent further damage to the injured area, reduce pain, and promote healing. Asking about allergies should have been done prior to administering antibiotics, checking immunization records is not a priority in this acute situation, and pain medication, while important, is secondary to stabilizing the injury.
The nurse notes variable decelerations on the fetal monitor strip. The most appropriate initial action would be to:
- A. Notify her doctor
- B. Start an IV
- C. Reposition the client
- D. Readjust the monitor
Correct Answer: C
Rationale: Variable decelerations are often caused by umbilical cord compression. Repositioning the client (e.g. to the left side) can relieve pressure on the cord and improve fetal oxygenation. Notifying the doctor or starting an IV are secondary if repositioning resolves the issue.
The nurse is assessing a client with suspected dehydration. Which finding is most indicative?
- A. Increased urine output
- B. Dry mucous membranes
- C. Bradycardia
- D. Fever
Correct Answer: B
Rationale: Dry mucous membranes are a classic sign of dehydration due to reduced fluid volume. Decreased (not increased) urine output, tachycardia, and fever may occur but are less specific.
A 30-year-old client in the third trimester of her pregnancy asks the nurse for advice about upper respiratory discomforts. She complains of nasal stuffiness and epistaxis, most noticeable on the left side. Which reply by the nurse is correct?
- A. It sounds as though you are coming down with a bad cold. I'll ask the doctor to prescribe a decongestant for relief of symptoms.'
- B. A good vaporizer will help; avoid the cool air kind. Also, try saline nose drops, and spend less time on your left side.'
- C. These discomforts are all a result of increased blood supply; one of the pregnancy hormones, estrogen, causes them.'
- D. This is most unusual. I'm sure your obstetrician will want you to see an ENT (ear, nose, throat) specialist.'
Correct Answer: C
Rationale: Decongestants may exaggerate the nasal stuffiness associated with pregnancy. Judicious use of decongestants and nasal sprays is advocated during pregnancy. Cool air vaporizers and saline drops may help to relieve the nasal stuffiness. Positioning on either lateral side does not decrease nasal stuffiness or prevent epistaxis. Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation, which contributes to epistaxis. The nurse may recommend cool air vaporizers and saline drops to help with the nasal stuffiness. Increased estrogen levels result in nasal mucosa edema with subsequent nasal stuffiness. Estrogen also promotes vasodilation discomforts associated with pregnancy.
The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
- A. Inspiration is longer than expiration
- B. Breath sounds are high pitched
- C. Breath sounds are slightly muffled
- D. Inspiration and expiration are equal
Correct Answer: D
Rationale: Inspiration is normally longer in vesicular areas. High-pitched sounds are normal in bronchial area. Muffled sounds are considered abnormal. Inspiration and expiration are equal normally in this area, and sounds are medium pitched.