Nokea
A client with dyspnea is being admitted to the medical unit. To best prepare for the client's arrival, the nurse should ensure that the client's bed is in which position?
- A. Trendelenburg
- B. Supine
- C. Prone
- D. Fowler's
Correct Answer: D
Rationale: Fowler's position (head elevated at 45-60 degrees) improves oxygenation by expanding the lungs, making it the best position for clients with dyspnea. Supine or prone positions restrict lung expansion, and Trendelenburg position (head down) can exacerbate breathing difficulties by increasing pressure on the lungs and diaphragm.
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A client with a history of alcohol abuse presents with confusion and unsteady gait. The nurse suspects Wernicke's encephalopathy. Which treatment should the nurse anticipate?
- A. Thiamine supplementation
- B. Folic acid replacement
- C. Intravenous glucose
- D. Magnesium sulfate administration
Correct Answer: A
Rationale: Wernicke's encephalopathy is a neurological condition commonly caused by a deficiency in thiamine, often seen in clients with chronic alcohol abuse. Thiamine supplementation is the primary treatment to prevent further neurological damage. Folic acid replacement (choice B) is not the correct treatment for Wernicke's encephalopathy. Intravenous glucose (choice C) may be necessary in some cases of Wernicke's encephalopathy, but thiamine supplementation takes precedence. Magnesium sulfate administration (choice D) is not indicated as the primary treatment for Wernicke's encephalopathy.
A male client with schizophrenia is socially reclusive and pacing in the hallway. What is the most important intervention for the nurse to implement?
- A. Take the client's temperature and blood pressure.
- B. Encourage the client to rest.
- C. Plan an activity that includes physical exercise.
- D. Carefully observe the client throughout the shift.
Correct Answer: D
Rationale: The correct answer is to carefully observe the client throughout the shift. In this situation, the client's behavior suggests agitation and restlessness, which could potentially escalate. Observation is crucial to monitor any changes in behavior, assess for signs of distress, and ensure the client's safety. Taking the client's temperature and blood pressure (Choice A) may not address the immediate need for managing the client's behavior. Encouraging the client to rest (Choice B) might not be effective if the client is highly agitated. Planning an activity that includes physical exercise (Choice C) could exacerbate the situation rather than address the current behavior. Therefore, the priority is to observe the client closely to provide appropriate support and intervention as needed.
A nurse assesses a young adult in the emergency room following a motor vehicle accident. Which of the following neurological signs is of most concern?
- A. Flaccid paralysis
- B. Pupils fixed and dilated
- C. Diminished spinal reflexes
- D. Reduced sensory responses
Correct Answer: B
Rationale: Fixed, dilated pupils are a sign of increased intracranial pressure or brain injury, indicating a potentially serious neurological condition. Flaccid paralysis, although concerning, may not always indicate immediate life-threatening issues. Diminished spinal reflexes and reduced sensory responses are important neurological assessments but are not as acutely concerning as fixed, dilated pupils in this context.
A client with Type 1 diabetes reports feeling shaky and lightheaded. The nurse checks the client's blood glucose level and it is 60 mg/dL. What action should the nurse take first?
- A. Give the client a glucagon injection
- B. Encourage the client to eat a high-protein snack
- C. Recheck the blood glucose level in 15 minutes
- D. Administer 15 grams of a fast-acting carbohydrate
Correct Answer: D
Rationale: The correct answer is D: Administer 15 grams of a fast-acting carbohydrate. The first step in treating hypoglycemia is to quickly raise the client's blood sugar level. Fast-acting carbohydrates like glucose tablets or juice are essential for this purpose. Giving a glucagon injection is typically reserved for severe hypoglycemia when the client is unable to take anything by mouth. Encouraging the client to eat a high-protein snack is not appropriate for immediate treatment of hypoglycemia. Rechecking the blood glucose level in 15 minutes is important after administering the fast-acting carbohydrate to ensure that the blood sugar has returned to a safe level.
A 4-year-old child falls off a tricycle and is admitted for observation. How can the nurse best facilitate the child's cooperation during the assessment?
- A. Ask the parent to hold the child during the assessment.
- B. Allow the child to play with a syringe without a needle.
- C. Ask the child to blow out the penlight as if to simulate success.
- D. Explain the function of each organ during the assessment.
Correct Answer: C
Rationale: Engaging the child in blowing out the penlight simulates play and can reduce fear, helping with cooperation during the assessment. Choice A is not recommended as it may increase anxiety by separating the child from the parent. Choice B is not appropriate as it involves playing with a syringe, which may not be safe or suitable. Choice D is not ideal for a 4-year-old child as understanding organ functions may be beyond their developmental level.