Nokea
A client on a 72-hour psychiatric hold experiences a panic attack while getting ready for the day. The nurse should provide the following interventions ranked by priority:
- A. stay with the client until the panic attack is over
- B. incorporate physical activity into the client's daily routine
- C. instruct the client to take slow, deep breaths
- D. reduce external stimuli in the immediate area
- E. work with the client to develop coping mechanisms
Correct Answer: A,D,C,E,B
Rationale: Priority order: Stay with the client (A) for safety, reduce stimuli (D) to calm the environment, instruct deep breathing (C) to manage symptoms, develop coping mechanisms (E) for future prevention, and incorporate physical activity (B) as a long-term strategy.
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The physician has ordered that a serum trough level be drawn for a medication. Which of the following is the correct time to draw blood for a trough level?
- A. At the midpoint in time between two scheduled doses of the drug.
- B. At the time the drug peaks.
- C. Immediately after a scheduled dose is administered.
- D. Immediately before a scheduled dose is due.
Correct Answer: D
Rationale: A trough level is drawn immediately before a scheduled dose (D) to measure the lowest drug concentration in the blood. Other times (A, B, C) do not reflect the trough level.
A client who has undergone a thyroidectomy complains of numbness, tingling, and stiffness in her hands, feet, and face as well as muscle tremors, spasmodic muscle contractions, and anxiety during the postoperative period. Which laboratory tests does the nurse anticipate that the physician will request?
- A. Hemoglobin.
- B. Sodium.
- C. Thyroid-stimulating hormone (TSH).
- D. Calcium.
Correct Answer: D
Rationale: Numbness, tingling, and muscle spasms post-thyroidectomy suggest hypocalcemia due to parathyroid gland disruption. The physician will likely request a calcium level test (D). Hemoglobin (A), sodium (B), and TSH (C) are not directly related to these symptoms.
A student nurse is developing a care plan for a 23-year-old woman with Meniere's disease. Which of the following would NOT be an expected intervention?
- A. administer narcotic pain medication PRN as ordered
- B. refer client to dietician to plan meals with reduced sodium levels
- C. assist client out of bed to shower and to toilet
- D. encourage client to eat several, similarly sized meals throughout the day
Correct Answer: A
Rationale: Meniere’s disease causes vertigo and hearing loss, not typically requiring narcotic pain medication. Low-sodium diets, assistance with mobility, and balanced meals help manage symptoms.
A non-immune nurse should not be assigned a client who has which of the vaccine-preventable airborne diseases? Select all that apply.
- A. tuberculosis
- B. influenza
- C. smallpox
- D. pertussis
Correct Answer: A,C
Rationale: Tuberculosis and smallpox are airborne, vaccine-preventable diseases posing risks to non-immune nurses. Influenza and pertussis are primarily droplet-transmitted.
A 25-year-old male is admitted in sickle cell crisis. Which of the following interventions would be of highest priority for this client?
- A. Taking hourly blood pressures with mechanical cuff
- B. Encouraging fluid intake of at least 200 mL per hour
- C. Position in high Fowler's with knee gatch raised
- D. Administering Tylenol as ordered
Correct Answer: B
Rationale: Hydration is the highest priority in sickle cell crisis to prevent further sickling of red blood cells and to promote blood flow, reducing the risk of complications.