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A client with a known history of panic disorder comes to the emergency department and states to the nurse, 'Please help me. I think I'm having a heart attack.' What is the priority nursing action?
- A. Assess the client's vital signs.
- B. Encourage the client to use relaxation techniques.
- C. Identify the manifestations related to the panic disorder.
- D. Determine what the client's activity involved when the pain started.
Correct Answer: A
Rationale: Clients with a panic disorder can experience acute physical symptoms, such as chest pain and palpitations. The priority is to assess the client's physical condition to rule out a physiological disorder for these signs and symptoms. Although options 2, 3, and 4 may be appropriate at some point in the care of the client, they are not the priority.
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The nurse is assigned to care for a client experiencing hypertonic labor contractions. The nurse plans to conserve the client's energy and promote rest by performing which intervention?
- A. Keeping the TV or radio on to provide distraction
- B. Assisting the client with breathing and relaxation techniques
- C. Keeping the room brightly lit so the client can watch her monitor
- D. Avoiding uncomfortable procedures such as intravenous infusions or epidural anesthesia
Correct Answer: B
Rationale: Breathing and relaxation techniques aid the client in coping with the discomfort of labor and conserving energy. Noise from a TV or radio and light stimulation does not promote rest. A quiet, dim environment would be more advantageous. Intravenous or epidural pain relief can be useful. Intravenous hydration can increase perfusion and oxygenation of maternal and fetal tissues and provide glucose for energy needs.
The nurse is performing a respiratory assessment on a client being treated for an asthma attack. The nurse determines that the client's respiratory status is worsening based upon which finding?
- A. Loud wheezing
- B. Wheezing on expiration
- C. Noticeably diminished breath sounds
- D. Increased displays of emotional apprehension
Correct Answer: C
Rationale: Noticeably diminished breath sounds are an indication of severe obstruction and impending respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. Clients with minor attacks may experience loud wheezes, whereas others with severe attacks may not wheeze. The client with severe asthma attacks may have no audible wheezing because of the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Emotional apprehension is likely whatever the degree of respiratory distress being experienced.
The nurse managing a client's post-supratentorial craniotomy care should assure that the client is maintained in which position?
- A. Prone
- B. Supine
- C. Semi-Fowler's
- D. Dorsal recumbent
Correct Answer: C
Rationale: Following a supratentorial craniotomy, the client should be maintained in a semi-Fowler's position (head of bed elevated 30 to 45 degrees) to promote venous drainage from the brain, reduce intracranial pressure, and prevent swelling at the surgical site. The prone position could increase pressure on the surgical site and impede breathing. The supine position may increase intracranial pressure due to poor venous drainage. The dorsal recumbent position, while flat with knees flexed, does not provide the elevation needed to reduce intracranial pressure effectively.
A hospitalized client awaiting repair of an unruptured cerebral aneurysm is frequently assessed by the nurse. Which assessment finding should the nurse identify as an early indication that the aneurysm has ruptured?
- A. Widened pulse pressure
- B. Unilateral motor weakness
- C. Unilateral slowing of pupil response
- D. A decline in the level of consciousness
Correct Answer: D
Rationale: Rupture of a cerebral aneurysm usually results in increased intracranial pressure (ICP). The first sign of pressure in the brain is a change in the level of consciousness. This change in consciousness can be as subtle as drowsiness or restlessness. Because centers that control blood pressure are located lower in the brain than those that control consciousness, blood pressure alteration is a later sign. Slowing of pupil response and motor weakness are also late signs.
The nurse teaching an older client about general hygienic measures for foot and nail care should include which instructions? Select all that apply.
- A. Wear knee-high hose to prevent edema.
- B. Soak and wash the feet daily using cool water.
- C. Use commercial removers for corns or calluses.
- D. Use over-the-counter preparations to treat ingrown nails.
- E. Apply lanolin or baby oil if dryness is noted along the feet.
- F. Pat the feet dry thoroughly after washing and dry well between toes.
Correct Answer: E,F
Rationale: The nurse should offer the following guidelines in a general hygienic foot and nail care program: Inspect the feet daily, including the tops and soles of the feet, the heels, and the areas between the toes; wash the feet daily using lukewarm water, and avoid soaks to the feet, thoroughly patting the feet dry and drying well between toes; and avoid cutting corns or calluses or using commercial removers. Additional general hygienic measures include gently rubbing lanolin, baby oil, or corn oil into the skin if dryness is noted along the feet or between the toes; filing the toe nails straight across and square (do not use scissors or clippers); avoiding the use of over-the-counter preparations to treat ingrown toenails and consulting a primary health care provider for these problems; and avoiding wearing elastic stockings (unless prescribed by a health care professional), knee-high hose, or constricting garters.