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A male client is admitted to the neurological unit. He has just sustained a C-5 spinal cord injury. Which assessment finding of this client warrants immediate intervention by the nurse?
- A. Is unable to feel sensation in the arms and hands.
- B. Has flaccid upper and lower extremities.
- C. Blood pressure is 110/70 and the apical pulse is 68.
- D. Respirations are shallow, labored, and 14 breaths/minute.
Correct Answer: D
Rationale: The correct answer is D because shallow, labored respirations at 14 breaths/minute indicate potential respiratory distress in a client with a C-5 spinal cord injury. This level of injury compromises the function of the diaphragm and intercostal muscles, leading to impaired respiratory effort. Immediate intervention is crucial to prevent respiratory failure and subsequent complications. Choices A and B are common findings in clients with spinal cord injuries and do not require immediate intervention. Choice C indicates stable vital signs within normal range, which do not necessitate immediate action.
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An elderly client with congestive heart failure (CHF) is admitted to the hospital. Which laboratory test result should the nurse expect to find?
- A. Elevated serum sodium level.
- B. Decreased brain natriuretic peptide (BNP) level.
- C. Increased serum creatinine level.
- D. Elevated hemoglobin and hematocrit levels.
Correct Answer: C
Rationale: The correct answer is C, increased serum creatinine level. In CHF, the heart's reduced pumping ability can lead to decreased blood flow to the kidneys, resulting in impaired kidney function. This can cause an elevation in serum creatinine level, indicating decreased kidney function. Elevated serum sodium level (A) is not typically seen in CHF, as patients often have fluid retention leading to dilutional hyponatremia. Decreased BNP level (B) is not expected in CHF, as BNP is released in response to increased ventricular stretching and volume overload. Elevated hemoglobin and hematocrit levels (D) are not directly related to CHF; they may be seen in conditions like dehydration or chronic hypoxia, but not specifically in CHF.
In evaluating a 10-year-old child with meningitis suspected of having diabetes insipidus, which finding is indicative of diabetes insipidus?
- A. Decreased urine specific gravity.
- B. Elevated urine glucose.
- C. Decreased serum potassium.
- D. Increased serum sodium.
Correct Answer: A
Rationale: The correct answer is A: Decreased urine specific gravity. In diabetes insipidus, there is an inability to concentrate urine, leading to decreased urine specific gravity. This is due to the decreased production or action of antidiuretic hormone (ADH). As a result, the kidneys are unable to reabsorb water efficiently, causing dilute urine with low specific gravity.
Incorrect choices:
B: Elevated urine glucose is more indicative of diabetes mellitus, not diabetes insipidus.
C: Decreased serum potassium is not a typical finding in diabetes insipidus.
D: Increased serum sodium can occur due to dehydration from excessive urination in diabetes insipidus, but it is not directly indicative of the condition.
A recently widowed middle-aged female client presents to the psychiatric clinic for evaluation and tells the nurse that she has 'little reason to live.' She describes one previous suicidal gesture and admits to having a gun in her home. To maintain the client's confidentiality and to help ensure her safety, which action is best for the nurse to implement?
- A. Encourage the client to remove the gun from her possession.
- B. Notify the client's healthcare provider of the availability of the weapon.
- C. Contact a person of the client's choosing to remove the weapon from the home.
- D. Call the local police department and have the weapon removed from the home.
Correct Answer: C
Rationale: The correct answer is C: Contact a person of the client's choosing to remove the weapon from the home. This option respects the client's autonomy and confidentiality while ensuring her safety.
1. Encouraging the client to remove the gun (Option A) may not guarantee immediate action and could potentially escalate the situation.
2. Notifying the client's healthcare provider (Option B) could breach confidentiality and may not result in immediate intervention.
3. Calling the police (Option D) could lead to a loss of trust and may not be necessary if the situation can be handled discreetly by someone the client trusts.
Therefore, option C is the best course of action as it respects the client's autonomy, maintains confidentiality, and ensures prompt removal of the weapon to enhance the client's safety.
Which intervention should the nurse implement to enhance the efficacy of the client's asthma medication therapy?
- A. Administer the albuterol inhaler before other inhaled medications.
- B. Provide oxygen via nasal cannula at 2 liters/minute.
- C. Encourage the client to drink three liters of fluids daily.
- D. Keep the client upright during nebulizer therapy.
Correct Answer: A
Rationale: The correct answer is A: Administer the albuterol inhaler before other inhaled medications. Administering albuterol first helps open airways, allowing better absorption of subsequent medications. Option B does not directly enhance medication efficacy. Option C promotes hydration but doesn't affect medication efficacy. Option D does not specifically enhance medication therapy.
Which client's laboratory value requires immediate intervention by a nurse?
- A. A client with GI bleeding who is receiving a blood transfusion and has a hemoglobin of 7 grams.
- B. A client with pancreatitis who has a fasting glucose of 190 mg/dl today and had 160 mg/dl yesterday.
- C. A client with hepatitis who is jaundiced and has a bilirubin level that is 4 times the normal value.
- D. A client with cancer who has an absolute neutrophil count < 500 today and had 2,000 yesterday.
Correct Answer: D
Rationale: The correct answer is D because a client with an absolute neutrophil count < 500 is at high risk for serious infections due to severe neutropenia. Neutrophils are crucial for fighting infections, and a low count puts the client at immediate risk. Therefore, intervention is required to prevent life-threatening complications.
Choice A: A hemoglobin of 7 grams in a client with GI bleeding receiving a blood transfusion indicates anemia, but it does not require immediate intervention unless the client is symptomatic.
Choice B: A fasting glucose of 190 mg/dl in a client with pancreatitis is elevated but does not require immediate intervention unless the client is symptomatic or experiencing complications.
Choice C: A bilirubin level 4 times the normal value in a jaundiced client with hepatitis is concerning but does not require immediate intervention unless there are signs of severe liver dysfunction or complications.