Nokea
A client with a history of multiple myeloma is admitted with complaints of bone pain. The nurse should give priority to:
- A. Administering analgesics
- B. Monitoring for hypercalcemia
- C. Administering chemotherapy
- D. Monitoring blood pressure
Correct Answer: B
Rationale: Bone pain in multiple myeloma is often due to bone destruction, which can cause hypercalcemia, so monitoring for hypercalcemia is the priority.
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A 14-year-old client has a history of lying, stealing, and destruction of property. Personal items of peers have been found missing. After group therapy, a peer approaches the nurse to report that he has seen the 14-year-old with some of the missing items. The best response of the nurse is to:
- A. Request that he explain to the group why he took personal items from peers
- B. Approach him when he is alone to inquire about his involvement in the incident
- C. Imply to him that you doubt his involvement in the incident and request his denial
- D. Confront him openly in group and request an apology
Correct Answer: B
Rationale: This answer is incorrect. There is no proof that he removed the missing items. This answer is correct. Anxiety and defensiveness are lessened if the individual is approached in this manner. This answer is incorrect. It is difficult for one to admit to wrongdoing with this approach. This answer is incorrect. He has not yet been proved guilty. Confrontation will only increase defensiveness and anxiety.
Joint Commission has established protocols for preventing surgical errors. Which steps are parts of that protocol?
- A. Circle the surgical site with a marker.
- B. Verify patient information with a designated patient representative.
- C. Designate operative site with a facility designated mark.
- D. Include a copy of the Advanced Directives on the chart before surgery.
- E. Verify patient information three times.
- F. Observe pre-op time out before proceeding with surgery.
Correct Answer: C, E, F
Rationale: Joint Commission protocols include marking the site with a facility-designated mark (C), verifying patient information multiple times (E), and performing a pre-op time-out (F). Circling the site (A) is not standard. Patient representative verification (B) and advance directives (D) are not part of site verification.
A newborn girl's father expresses concern that the newborn does not have good control of her hands and arms. It is important for the father to realize certain neurological patterns that characterize the newborn:
- A. Mild hypotonia is expected in the upper extremities.
- B. Purposeless, uncoordinated movements of the arms are indicative of neurological dysfunction.
- C. Function progresses in a head-to-toe, proximal-distal fashion.
- D. Asymmetrical movement of the extremities is not unusual and will disappear with maturation of the central nervous system.
Correct Answer: C
Rationale: Term neonates are predominantly in a flexed position with strong active muscle tone that increases. Newborns are slightly hypertonic. Neonatal movements may be jerky and uncoordinated as the neonate works against gravity in contrast to the buoyancy of the amniotic fluid. Jerky movements must be differentiated from the tremors of hypoglycemia, hypocalcemia, and neurological dysfunction. Growth of the newborn progresses in a cephalocaudal, proximal-distal fashion. Knowledge regarding infant development may facilitate parental involvement and infant stimulation. Asymmetrical movements of the extremities are indicative of neurological dysfunction.
A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurse's first action when admitting the client will be to:
- A. Obtain vital signs
- B. Connect the client to the cardiac monitor
- C. Ask the client if he is still having chest pain
- D. Complete the history profile
Correct Answer: B
Rationale: Obtaining vital signs is important after connecting the client to the monitor because vital signs should be stable before the client is discharged from the emergency room. All are important, but the first priority is to monitor the client's rhythm. If the client is in severe pain, pain medication should be given after connecting him to the monitor and obtaining vital signs. Completion of the history profile is the least important of the nursing actions.
A client's wife is concerned over his behavior in recent months. He has been diagnosed with Parkinson's disease, and she is telling his nurse that he has been doing 'strange things.' The nurse reassures the wife that the following behavior is normal with Parkinson's disease:
- A. Your husband will experience some periods of muscle flaccidity. Be sure to make him sit down during these periods.'
- B. Your husband may move his hands in motions that look like he is rolling a pill between his fingers.'
- C. Twitching of the muscles is to be expected and can occur at any time during the day.'
- D. Parkinson's disease causes severe pain in the joints. You should give your husband Tylenol at those times.'
Correct Answer: B
Rationale: Clients with Parkinson's disease generally experience stiffness and rigid movement. Pill-rolling movements are a symptom experienced by the Parkinson client. Twitching of the muscles is not an expected symptom of Parkinson's disease. Parkinson's disease does not cause joint pain. Mild muscular pain may be present.