Nokea
A male client with a head injury regains consciousness and the normal loss. Which of the following nursing statements is most appropriate as the client awakens?
- A. I'll get your family.
- B. Can you tell me your name and where you live?
- C. I'll bet you're a little confused right now.
- D. You are in the hospital. You were in an accident and unconscious.
Correct Answer: D
Rationale: Providing clear, concise orientation information is most appropriate for a client regaining consciousness to reduce confusion and anxiety. Calling family, asking for personal details, or assuming confusion may overwhelm or distress the client.
You may also like to solve these questions
A client has been admitted with acute renal failure. What should the nurse do? Select all that apply.
- A. Elevate the head of the bed 30 to 45 degrees.
- B. Take vital signs.
- C. Establish an I.V. access site.
- D. Call the admitting physician for orders.
- E. Contact the hemodialysis unit.
Correct Answer: B,C,D
Rationale: Taking vital signs, establishing IV access, and contacting the physician are immediate actions to assess and stabilize the client with acute renal failure.
A client with Buerger's disease has established a goal to stop smoking. Which medication would be the most helpful in attaining this goal?
- A. Zyban (Bupropion)
- B. Nicotine (Nicotrol)
- C. Nitroglycerin (Tridil)
- D. Ibuprofen (Advil)
Correct Answer: A
Rationale: Zyban (bupropion) is an antidepressant that reduces nicotine cravings and withdrawal symptoms, making it effective for smoking cessation in Buerger's disease. Nicotine replacement (Nicotrol) may help but continues nicotine exposure, nitroglycerin is for angina, and ibuprofen is irrelevant.
What is a key nursing intervention for a client receiving peritoneal dialysis?
- A. Monitor for signs of peritonitis.
- B. Restrict protein intake.
- C. Administer anticoagulants.
- D. Limit ambulation.
Correct Answer: A
Rationale: Peritonitis is a serious complication of peritoneal dialysis, requiring vigilant monitoring.
A client is given amiodarone (Cordarone) in the emergency department for a dysrhythmia. Which of the following indicates the drug is having the desired effect?
- A. The ventricular rate is increasing.
- B. The absent pulse is now palpable.
- C. The number of premature ventricular contractions is decreasing.
- D. The fine ventricular fibrillation changes to coarse ventricular fibrillation.
Correct Answer: C
Rationale: Amiodarone treats ventricular arrhythmias. A decrease in PVCs indicates the drug is stabilizing the cardiac rhythm, its desired effect.
Which of the following would be an expected finding in a client with adrenal crisis (addisonian crisis)?
- A. Fluid retention.
- B. Pain.
- C. Peripheral edema.
- D. Hunger.
Correct Answer: B
Rationale: Pain, particularly abdominal, is a common symptom in addisonian crisis due to electrolyte imbalances and hypotension.