Nokea
A hospitalized Native American patient tells the nurse that later in the day a medicine man from his tribe is coming to perform a healing ceremony to return his world to balance. What should the nurse recognize about this situation?
- A. The patient does not adhere to an organized,formal religion.
- B. The patient’s spiritual needs may be met by traditional rituals.
- C. The patient’s spiritual needs may be met by traditional rituals.
- D. The patient may be putting his health in jeopardy by relying on rituals.
Correct Answer: B
Rationale: Traditional rituals such as those performed by a medicine man can meet the spiritual needs of Native American patients. This approach respects their cultural beliefs without undermining conventional medical treatment.
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The physician has written orders for the client with Excess Fluid Volume. The client's morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time?
- A. Weigh client every morning
- B. Maintain accurate intake and output
- C. Restrict fluid to 1500 mL per day
- D. Administer furosemide (Lasix) 40 mg IV push
Correct Answer: D
Rationale: The correct answer is D: Administer furosemide (Lasix) 40 mg IV push. This is the priority because the client is showing signs of fluid volume excess, such as weight gain, pitting edema, and crackles, which indicate fluid overload in the lungs. Furosemide is a loop diuretic that helps to remove excess fluid from the body quickly, making it crucial in managing excess fluid volume in this situation. Weighing the client daily (A) is important but not as urgent as addressing the immediate symptoms of fluid overload. Maintaining accurate intake and output (B) is essential for overall fluid balance but does not address the immediate excess fluid volume. Fluid restriction (C) may be needed in the long term, but immediate intervention with furosemide is necessary to prevent worsening of symptoms and potential complications.
When assessing a client who has just undergone a cardioversion, the nurse finds the respirations are 12. Which action should the nurse take first?
- A. Try to vigorously stimulate normal breathing.
- B. Ask the RN to assess the vital signs.
- C. Measure the pulse oximetry.
- D. Continue to monitor respirations.
Correct Answer: C
Rationale: Pulse oximetry provides critical data on oxygenation.
Amitriptyline (Elavil) is prescribed for a patient with chronic pain from fibromyalgia. When the nurse explains that this drug is an antidepressant, the patient states that she is in pain, not depressed. What is the nurse’s best response to the patient?
- A. Antidepressants will improve the patient’s attitude and prevent a negative emotional response to the pain.
- B. Chronic pain almost always leads to depression, and the use of this drug will prevent depression from occurring.
- C. Some antidepressant drugs relieve pain by releasing neurotransmitters that prevent pain impulses from reaching the brain.
- D. Certain antidepressant drugs are metabolized in the liver to substances that numb the ends of nerve fibers, preventing the onset of pain.
Correct Answer: C
Rationale: The correct answer is C. Amitriptyline relieves pain by modulating neurotransmitter release, not solely by treating depression.
Describe the signs and symptoms of bipolar disorder.
- A. Increased alertness
- B. Lower immune response
- C. Faster metabolism
- D. Enhanced digestion
Correct Answer: D
Rationale: The correct answer is D because it is the most appropriate response based on physiological and medical principles.
The following data are organized according to Gordon’s functional health patterns.
- A. 78-year-old woman
- B. Married, three grown children who all live out of town
- C. Cares for invalid husband in home with help of daily homemaker
- D. Vision corrected with glasses; hearing normal
Correct Answer: A
Rationale: N/A