Nokea
The nurse is initiating the client's plan of care. Which of the following interventions should the nurse plan to implement? Select all that apply
- A. Provide a low-stimulation environment
- B. Maintain bed rest
- C. Give antihypertensive medication.
- D. Administer betamethasone
- E. Monitor intake and output hourly
- F. Obtain a 24-hr urine specimen
- G. Perform a vaginal examination every 12 hr
Correct Answer: A, B, C, D, E, F
Rationale: Correct Answer: A, B, C, D, E, F
Rationale:
A: Providing a low-stimulation environment promotes rest and reduces stress.
B: Maintaining bed rest may be necessary for certain conditions to prevent complications.
C: Giving antihypertensive medication helps control blood pressure.
D: Administering betamethasone can be part of the treatment plan for certain conditions.
E: Monitoring intake and output hourly helps assess fluid balance and kidney function.
F: Obtaining a 24-hr urine specimen is a common diagnostic test to assess kidney function.
Summary:
Choice G is incorrect as performing vaginal examinations every 12 hours is unnecessary and invasive.
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Drag words from the choices below to fill in each blank in the following sentence. The client is at greatest risk for developing-----and-----
- A. Placental Abruption
- B. Hypoglycemia
- C. Heart failure
- D. Cervical insufficiency
- E. Seizures
Correct Answer: C,E
Rationale: The correct answer is C, Heart failure, and E, Seizures. The client is at greatest risk for developing heart failure and seizures due to complications during pregnancy. Heart failure can occur due to the increased stress on the heart from pregnancy, especially in individuals with pre-existing heart conditions. Seizures can arise from conditions like eclampsia, which is a severe form of preeclampsia characterized by high blood pressure and organ damage. Placental abruption (A) is a separation of the placenta from the uterus, not directly related to heart failure or seizures. Hypoglycemia (B) is low blood sugar levels, which may occur but is not the greatest risk in this scenario. Cervical insufficiency (D) is the inability of the cervix to stay closed during pregnancy, which is not directly linked to heart failure or seizures.
A nurse is caring for a client whose child died from cancer. The client states, 'It's hard to go on without him.' Which of the following questions should the nurse ask the client first?
- A. What has helped you through difficult times in the past?'
- B. Has anyone in your family committed suicide?'
- C. Is there anyone you would like involved in your care?'
- D. Are you thinking about ending your life?'
Correct Answer: D
Rationale: The correct question to ask first is D: "Are you thinking about ending your life?" This is important to assess the client's risk of suicide, as the statement "It's hard to go on without him" can indicate suicidal ideation. It is crucial to address safety concerns immediately. Asking about coping strategies (A) can come later. Inquiring about family suicide history (B) may not be relevant at this stage. Involving others in care (C) is important but not as urgent as assessing suicidal thoughts.
A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender?
- A. The client has a history of alcohol use disorder
- B. The client has a history of asthma.
- C. The client takes vitamin C daily
- D. The client takes furosemide twice daily
Correct Answer: B
Rationale: The correct answer is B. Lavender oil can exacerbate asthma symptoms due to its potential to irritate the respiratory system. Asthma is a contraindication because it can trigger or worsen asthma attacks. Alcohol use disorder (A), vitamin C intake (C), and furosemide use (D) are not contraindications for using lavender oil. Alcohol use disorder does not directly interact with lavender oil. Vitamin C intake and furosemide use do not have known interactions with lavender oil that would contraindicate its use.
A nurse is planning teaching for a client who has a newly implanted implantable cardioverter/defibrillator. Which of the following information should the nurse include?
- A. Expect to have a rapid pulse rate for the first few weeks.
- B. Wear loose-fitting clothing
- C. Return in two weeks for a follow-up MRI,
- D. Resume tub baths and swimming after 74 hr.
Correct Answer: B
Rationale: The correct answer is B: Wear loose-fitting clothing. This is important because tight clothing can put pressure on the implantable cardioverter/defibrillator site, leading to discomfort or dislodgement. Choice A is incorrect because a rapid pulse rate is not expected post-implantation. Choice C is incorrect as MRI is contraindicated due to the presence of the device. Choice D is incorrect as tub baths and swimming should be avoided until the incision site is fully healed to prevent infection.
A nurse is discussing discharge plans with an older adult client who lives alone and has left-sided weakness following a stroke. Which of the following information is the priority for the nurse to discuss?
- A. Reviewing information about support groups for individuals who have had a stroke
- B. Obtaining an alert system to get help in case of a fall
- C. Providing information about available transportation resources
- D. Choosing an agency to provide home physical therapy
Correct Answer: B
Rationale: The correct answer is B: Obtaining an alert system to get help in case of a fall. This is the priority because the client's left-sided weakness puts them at risk for falls, which can have serious consequences. Having an alert system ensures they can get immediate help if a fall occurs, potentially preventing injuries or complications. Reviewing support groups (A) can be beneficial but is not as urgent. Providing transportation resources (C) and choosing a home physical therapy agency (D) are important but do not address the immediate safety concern of potential falls.