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A client on a psychiatric unit is glaring across the room and pointing a finger at empty space and yelling. What is the nurse's best response to the client's behavior?
- A. Say to him, 'There is no one there. Keep your voice down.'
- B. Escort the client to his room
- C. Restrain the client
- D. Offer PRN haloperidol (Haldol) as ordered
Correct Answer: B
Rationale: Escorting the client to a quieter space de-escalates agitation and ensures safety, addressing potential psychosis calmly.
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While a client is receiving TPN, it is MOST important for the nurse to monitor
- A. vital signs and level of consciousness.
- B. arterial blood gases and liver enzymes.
- C. serum glucose and electrolytes.
- D. skin turgor and daily weights.
Correct Answer: C
Rationale: TPN can cause hyperglycemia and electrolyte imbalances, making serum glucose and electrolyte monitoring critical. Options A, B, and D are less specific.
Which of the following laboratory results would suggest to the emergency room nurse that a client admitted after a severe motor vehicle crash is in acidosis?
- A. Hemoglobin 15 gm/dl
- B. Chloride 100 mEq/L
- C. Sodium 130 mEq/L
- D. Carbon dioxide 20 mEq/L
Correct Answer: D
Rationale: Serum carbon dioxide is an indicator of acid-base status. This finding would indicate acidosis.
The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure?
- A. Standing and sitting
- B. In both arms
- C. After exercising
- D. Supine position
Correct Answer: B
Rationale: In both arms. This ensures accuracy, as stenosis in one subclavian artery could cause a false reading.
A client with end stage renal disease has been managed by peritoneal dialysis. Which finding should be reported to the doctor immediately?
- A. The amount of dialysate return is less than that instilled.
- B. The client complains of abdominal pain and nausea.
- C. The dialysate return is colorless in appearance.
- D. The client has lost two pounds in the last week.
Correct Answer: B
Rationale: Complaints of abdominal pain, nausea, fever, and return of cloudy dialysate should be reported to the physician since they are indications of peritonitis. Diminished or slow return of dialysate, as mentioned in answer A, is managed by having the client turn side to side or move about to facilitate return flow, so it is incorrect. Answers C and D are favorable findings that do not require intervention; therefore, they are incorrect.
After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone.
- A. Which nursing diagnosis is a priority for a client with left-sided hemiparesis post-CVA?
- B. Alteration in mobility related to paralysis.
- C. Alteration in skin integrity related to decrease in tissue oxygenation.
- D. Alteration in skin integrity related to immobility.
- E. Alteration in communication related to decrease in thought processes.
Correct Answer: B
Rationale: Decreased tissue oxygenation from impaired circulation in hemiparesis is the leading cause of skin breakdown, making this the priority nursing diagnosis. Mobility and immobility are concerns, but tissue perfusion is more critical, and communication issues are more relevant to right-sided CVA.