Nokea
A client with antisocial personality disorder repeatedly requests a specific nurse be assigned to him and is belligerent when another nurse is assigned. What action should the charge nurse implement?
- A. Remind the client that nurse assignments are not based on patient requests
- B. Assign the nurse requested by the client to avoid further conflict
- C. Tell the client that he can request a different nurse if unhappy
- D. Explain the situation calmly and reinforce the rules regarding nurse assignments
Correct Answer: A
Rationale: The correct action for the charge nurse to implement is to remind the client that nurse assignments are not based on patient requests. In this situation, it is essential to establish boundaries and communicate that nurse assignments are made based on clinical decisions, not patient preferences. Option B is incorrect because it compromises the principle of fairness in nurse assignments. Option C is incorrect as it encourages the client's behavior by allowing him to request a different nurse based on personal preferences. Option D is also incorrect as it does not address the issue of patient manipulation and reinforces inappropriate behavior.
You may also like to solve these questions
During a thyroid storm, what is the nurse's priority intervention for a client experiencing increased heart rate and tremors?
- A. Administer antithyroid medications as prescribed.
- B. Administer a beta-blocker to control the heart rate.
- C. Monitor the client's temperature closely.
- D. Prepare the client for an emergency thyroidectomy.
Correct Answer: A
Rationale: The correct answer is to administer antithyroid medications as prescribed during a thyroid storm. Antithyroid medications help control the overproduction of thyroid hormones, which is crucial in managing symptoms such as increased heart rate and tremors. These symptoms can be life-threatening if not promptly addressed. Administering a beta-blocker (Choice B) may help control the heart rate, but addressing the underlying cause with antithyroid medications is the priority. Monitoring the client's temperature (Choice C) is important but not the priority intervention during a thyroid storm. Lastly, preparing the client for an emergency thyroidectomy (Choice D) is not the initial intervention for managing symptoms of a thyroid storm.
A client is admitted with an epidural hematoma after a skateboarding accident. How should the nurse differentiate the vascular source of intracranial bleeding?
- A. Monitor for clear fluid leakage from the nose.
- B. Assess for rapid onset of decreased level of consciousness.
- C. Check for bruising around the head and neck.
- D. Assess for changes in pupil size and reactivity.
Correct Answer: B
Rationale: An epidural hematoma is characterized by a rapid onset of symptoms, including decreased level of consciousness, due to arterial bleeding, which differentiates it from other types of intracranial hemorrhage. Monitoring for clear fluid leakage from the nose (choice A) is more indicative of a basilar skull fracture and cerebrospinal fluid leak. Checking for bruising around the head and neck (choice C) is more suggestive of soft tissue injuries or facial fractures. Assessing for changes in pupil size and reactivity (choice D) is essential in evaluating traumatic brain injuries, but it is not specific to differentiating the vascular source of intracranial bleeding in an epidural hematoma.
The nurse is providing care for a client with heart failure who is prescribed furosemide. Which laboratory value should the nurse monitor closely?
- A. Calcium level
- B. Sodium level
- C. Magnesium level
- D. Potassium level
Correct Answer: D
Rationale: The correct answer is D: Potassium level. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Monitoring potassium levels is crucial to prevent complications such as cardiac arrhythmias. While calcium, sodium, and magnesium levels are important in various conditions and treatments, they are not the primary electrolyte affected by furosemide.
An adult male is brought to the ER after a motorcycle accident with periorbital bruising and bloody drainage from both ears. Which finding requires immediate attention?
- A. Rebound abdominal tenderness.
- B. Diminished breath sounds bilaterally.
- C. Rib pain with deep inspiration.
- D. Projectile vomiting.
Correct Answer: D
Rationale: In this scenario, the patient's periorbital bruising and bloody drainage from both ears suggest a severe head injury. Projectile vomiting is a red flag symptom that may indicate increased intracranial pressure, which requires immediate attention to prevent further neurological deterioration. Rebound abdominal tenderness (choice A) typically indicates peritonitis and is not directly related to the primary head injury. Diminished breath sounds bilaterally (choice B) suggest a pneumothorax or hemothorax, which are important but not as immediately life-threatening in this context. Rib pain with deep inspiration (choice C) is concerning for rib fractures or pulmonary contusion, which are also important but do not take precedence over addressing the potential increased intracranial pressure.
A client with pneumonia is receiving antibiotics and oxygen therapy. What assessment finding requires immediate intervention?
- A. Productive cough with yellow sputum.
- B. Oxygen saturation of 88%.
- C. Respiratory rate of 20 breaths per minute.
- D. Heart rate of 90 beats per minute.
Correct Answer: B
Rationale: An oxygen saturation of 88% indicates hypoxemia, which is a critical condition requiring immediate intervention to improve oxygenation. Hypoxemia can lead to tissue hypoxia and further complications. A productive cough with yellow sputum is common in pneumonia but may not require immediate intervention unless it worsens or is associated with other concerning symptoms. A respiratory rate of 20 breaths per minute is within the normal range, indicating adequate ventilation. A heart rate of 90 beats per minute is also within a normal range and may not require immediate intervention unless it is accompanied by other abnormal findings.