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A healthcare professional is collecting data from a client who is experiencing post-traumatic stress disorder (PTSD). Which of the following manifestations should the healthcare professional expect?
- A. Hyperactivity
- B. Hypervigilance
- C. Restlessness
- D. Avoidance of social situations
Correct Answer: B
Rationale: Hypervigilance is a common manifestation of PTSD characterized by heightened alertness and fear of danger. This heightened state of awareness can lead to irritability, difficulty concentrating, and sleep disturbances. Choices A, C, and D are incorrect. Hyperactivity is not typically associated with PTSD; restlessness may be present but is not the primary manifestation, and avoidance of social situations is more commonly seen in conditions like social anxiety disorder rather than PTSD.
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A client with a pressure ulcer is being cared for by a nurse. Which of the following is the most appropriate action?
- A. Use a phenol solution to clean the wound
- B. Place a warm compress over the wound
- C. Cleanse the wound from the center outwards
- D. Administer antibiotics prophylactically
Correct Answer: C
Rationale: Cleaning a wound from the center outwards is the most appropriate action as it helps prevent the spread of infection. Choice A is incorrect as phenol solutions can be harmful to the wound and delay healing. Choice B may increase the risk of infection as warmth can promote bacterial growth. Choice D is unnecessary unless there are signs of infection present.
What are the primary goals of post-operative care for a patient who has undergone abdominal surgery?
- A. Pain Management
- B. Wound Care
- C. Prevention of Complications
- D. Digestive Function
Correct Answer: A
Rationale: The correct answer is A: Pain Management. After abdominal surgery, one of the primary goals of post-operative care is to manage the patient's pain effectively to ensure their comfort and promote recovery. While wound care, prevention of complications, and ensuring digestive function are also important aspects of post-operative care, pain management takes precedence as it directly impacts the patient's well-being and recovery process.
A nurse is caring for a client with dementia who is at risk of falls. What is the most appropriate intervention?
- A. Use a bed exit alarm to notify staff of attempts to leave the bed
- B. Raise all four side rails for safety
- C. Encourage frequent ambulation with assistance
- D. Use restraints to prevent the client from getting out of bed
Correct Answer: A
Rationale: The most appropriate intervention for a client with dementia at risk of falls is to use a bed exit alarm to notify staff of attempts to leave the bed. This intervention allows for timely assistance and prevents falls. Raising all four side rails (Choice B) can lead to entrapment or agitate the client. Encouraging frequent ambulation with assistance (Choice C) may not be suitable for a client at high risk of falls. Using restraints (Choice D) should be avoided as they can increase agitation, risk of injury, and have ethical implications.
A nurse is caring for a client who has coronary artery disease (CAD) and is receiving aspirin therapy. Which of the following findings should the nurse report to the provider?
- A. History of gastrointestinal bleeding
- B. Prothrombin time of 12 seconds
- C. Platelet count of 180,000/mm³
- D. Creatinine level of 1.0 mg/dL
Correct Answer: A
Rationale: The correct answer is A: History of gastrointestinal bleeding. Aspirin therapy is contraindicated in clients with a history of gastrointestinal bleeding because aspirin can further increase the risk of bleeding. Option B, prothrombin time of 12 seconds, is within the normal range and does not indicate a concern related to aspirin therapy. Option C, platelet count of 180,000/mm³, is also within the normal range and does not suggest a need for reporting to the provider in the context of aspirin therapy. Option D, creatinine level of 1.0 mg/dL, is within the normal range and is not directly related to aspirin therapy in this scenario.
What should a healthcare professional assess in a patient presenting with symptoms of a stroke?
- A. Assess facial drooping
- B. Monitor speech difficulties
- C. Evaluate arm weakness
- D. Check for time of onset of symptoms
Correct Answer: A
Rationale: When assessing a patient with suspected stroke symptoms, it is crucial to check for facial drooping as it can be a sign of facial nerve weakness, which is a common indicator of stroke. While monitoring speech difficulties and evaluating arm weakness are also important assessments in stroke cases, they are secondary to facial drooping. Checking for the time of onset of symptoms is essential to determine eligibility for time-sensitive treatments like thrombolytic therapy, but when prioritizing assessments, facial drooping takes precedence.