Nokea
A client with a prescription for "do not resuscitate" (DNR) begins to manifest signs of impending death. After notifying the family of the client's status, what priority action should the nurse implement?
- A. Assess the client's need for pain medication
- B. Document the impending signs of death
- C. Inform the nurse manager of the client's status
- D. Communicate the client's status to the chaplain
Correct Answer: A
Rationale: Assessing the client's need for pain medication is the priority action as it ensures comfort at the end of life. Pain management is crucial in providing comfort and dignity to clients during their final moments. Documenting impending signs of death (choice B) is important but not the immediate priority over addressing the client's comfort. Updating the nurse manager (choice C) and informing the chaplain (choice D) can follow once the client's immediate needs are met.
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While eating at a restaurant, a gravid woman begins to choke and is unable to speak. What action should the nurse who witnesses the event take?
- A. Cardiopulmonary resuscitation with uterine tilt
- B. The Heimlich maneuver using chest thrusts
- C. The Heimlich maneuver using subdiaphragmatic thrusts
- D. Call 911 immediately then begin cardiopulmonary resuscitation
Correct Answer: C
Rationale: The correct action for the nurse to take when a pregnant woman is choking and unable to speak is to perform the Heimlich maneuver using subdiaphragmatic thrusts. This technique is recommended for a pregnant woman to prevent harm to the fetus. Option A, cardiopulmonary resuscitation with uterine tilt, is not indicated for a choking episode. Option B, the Heimlich maneuver using chest thrusts, can potentially harm the gravid uterus. Option D, calling 911 immediately before providing assistance, can lead to a delay in addressing the immediate choking emergency.
Where should the nurse choose as the best location to begin a screening program for hypothyroidism?
- A. A business and professional women's group.
- B. An African-American senior citizens center.
- C. A daycare center in a Hispanic neighborhood.
- D. An after-school center for Native-American teens.
Correct Answer: B
Rationale: The best location for beginning a screening program for hypothyroidism would be an African-American senior citizens center. This choice is the most suitable as hypothyroidism is more prevalent among older adults, and African-American seniors are at a higher risk for this condition due to various factors like genetics and lifestyle. Choices A, C, and D are less appropriate because hypothyroidism is not specifically linked to business and professional women, Hispanic children, or Native-American teens. Targeting the high-risk group, which in this case, are African-American seniors, increases the chances of successful screening and early detection.
The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be included in the discharge teaching?
- A. Do not read with direct lighting for 6 weeks
- B. Avoid straining during stool passage, bending, or lifting heavy objects
- C. Irrigate conjunctiva with ophthalmic saline after applying antibiotic ointment
- D. Limit exposure to sunlight during the first 2 weeks while the cornea is healing
Correct Answer: B
Rationale: The correct instruction to include in the discharge teaching for a client following cataract extraction is to 'Avoid straining during stool passage, bending, or lifting heavy objects.' This is crucial to prevent increased intraocular pressure after surgery, which can be harmful. Reading with direct lighting can strain the eyes but is not the primary concern post-cataract surgery. Irrigating the conjunctiva before applying antibiotic ointment is not a standard practice and may not be necessary. While limiting sunlight exposure is important for eye protection, it is secondary to avoiding activities that can increase intraocular pressure.
A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care?
- A. Encourage the use of corrective lenses during the day
- B. Practice visual exercises that focus on a still object
- C. Alternate an eye patch from eye every 2 hours
- D. Teach techniques for scanning the environment
Correct Answer: D
Rationale: The correct intervention for a client with multiple sclerosis experiencing scotomas and limited peripheral vision is to teach techniques for scanning the environment. This intervention helps the client compensate for vision loss by learning how to scan and explore their surroundings effectively. Encouraging the use of corrective lenses may not address the issue of scotomas, and visual exercises focusing on a still object may not enhance peripheral vision. Alternating an eye patch every 2 hours is not typically indicated for scotomas in multiple sclerosis, making it an incorrect choice.
What is the best response when a two-year-old boy begins to cry when his mother starts to leave?
- A. Say, 'Let's wave bye-bye to Mommy.'
- B. Say, 'Let me read this book to you.'
- C. Say, 'Two-year-olds usually stop crying the minute the parent leaves.'
- D. Say, 'Now, now, be a big boy, Mommy will be back soon.'
Correct Answer: B
Rationale: The best response in this situation is to offer a distraction to the child. Reading a book can help soothe the child during separation from the parent by redirecting their attention. Choice A might not be as effective as providing a distraction like reading a book. Choice C dismisses the child's feelings and generalizes behavior, which is not helpful. Choice D diminishes the child's emotions and does not provide a constructive way to help the child cope with the separation anxiety.