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A client with a head injury is admitted to the hospital. Which finding indicates a need for immediate intervention?
- A. Glasgow Coma Scale (GCS) score of 15.
- B. Pupils are equal and reactive to light.
- C. Client is drowsy but arousable.
- D. Client does not remember the events leading to the injury.
Correct Answer: C
Rationale: In a client with a head injury, being drowsy but still arousable can be a sign of increased intracranial pressure, which necessitates immediate intervention. This presentation may indicate a deterioration in neurological status, requiring prompt assessment and management to prevent further complications. Choices A, B, and D are not indicative of an immediate need for intervention in this scenario. A Glasgow Coma Scale (GCS) score of 15 indicates the highest level of consciousness; pupils being equal and reactive to light suggest intact cranial nerve function, and memory loss about the injury event is common in head injuries and does not necessarily warrant immediate intervention.
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During the physical assessment, which finding should the nurse recognize as a normal finding?
- A. Regular pulsation at the epigastric area when the client is supine.
- B. A loud, harsh murmur at the second right intercostal space.
- C. Dullness over the lung fields.
- D. Increased tactile fremitus.
Correct Answer: A
Rationale: The regular pulsation at the epigastric area when the client is supine is a normal finding. This phenomenon is caused by the regular and recurrent expansion and contraction of an artery due to waves of pressure caused by the ejection of blood from the left ventricle. Choices B, C, and D describe abnormal findings during a physical assessment. A loud, harsh murmur at the second right intercostal space indicates an abnormal heart sound, dullness over the lung fields may suggest consolidation or fluid in the lungs, and increased tactile fremitus can be a sign of lung consolidation or pathology.
An older client requiring total care resides with a family consisting of two daughters who take shifts providing care around-the-clock. During a home visit, the daughters ask the nurse about resources that are available for client care while they attend a scheduled family reunion. Which information is best for the nurse to provide?
- A. propose the family seek assistance for care in the area of the reunion's location
- B. tell the caregivers to consider hiring a private duty nurse during the time away
- C. advise to have a case management evaluation of the client's home environment
- D. suggest social services be contacted to find a respite care facility for the client
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is preparing an orientation class for new employees at an inner-city clinic that serves a low-income population. Which information should the nurse include in the presentation to these new employees?
- A. A lack of transportation is the major impediment for the clinic's clients.
- B. Basic physiological needs are likely to be unmet in this clinic's client population.
- C. Printed material is less effective for this population that has limited reading skills.
- D. A group education class is often poorly attended by non-compliant clients.
Correct Answer: A
Rationale: The correct answer is A. Addressing transportation issues is crucial when working with low-income populations as lack of transportation can be a significant barrier to accessing healthcare services. This information is important for new employees to understand the challenges faced by the clinic's clients and to strategize ways to overcome this barrier. Choices B, C, and D are incorrect because while they may be relevant considerations, addressing transportation barriers should be a priority given its impact on accessing care for this specific population.
During a home visit, the nurse observes that a client with limited mobility has difficulty preparing meals. What should the nurse do first?
- A. suggest that the client use a meal delivery service
- B. assist the client in meal planning
- C. refer the client to a dietitian
- D. educate the client on easy-to-prepare healthy meals
Correct Answer: B
Rationale: Assisting the client in meal planning is the most appropriate initial action as it addresses the immediate issue of meal preparation. By helping the client plan meals according to their dietary needs and limitations, the nurse can support the client in maintaining a healthy diet despite limited mobility. While suggesting a meal delivery service (Choice A) may be a viable option, assisting in meal planning allows for more personalized and sustainable solutions. Referring the client to a dietitian (Choice C) may be necessary for specialized nutritional advice but is not the first step in addressing the immediate concern. Educating the client on easy-to-prepare healthy meals (Choice D) could be beneficial, but meal planning is a more comprehensive approach to ensure the client's dietary needs are met consistently.
A client with a history of hypertension is prescribed enalapril (Vasotec). Which statement by the client indicates a need for further teaching?
- A. I will monitor my blood pressure regularly.
- B. I will report any signs of infection to my healthcare provider.
- C. I will avoid using salt substitutes.
- D. I will increase my intake of potassium-rich foods.
Correct Answer: D
Rationale: The correct answer is D. Increasing potassium intake can lead to hyperkalemia, especially in clients taking ACE inhibitors like enalapril. Hyperkalemia is a potential side effect of ACE inhibitors and can be exacerbated by consuming potassium-rich foods. Monitoring blood pressure regularly (A) is important when taking antihypertensive medications. Reporting signs of infection (B) is crucial as ACE inhibitors can lower the immune response. Avoiding salt substitutes (C) is necessary because they may contain potassium chloride, leading to increased potassium levels, which can be harmful in combination with ACE inhibitors.