Nokea
A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?
- A. A client who was administered erythromycin for acute glomerulonephritis and reports reddish-brown urinary output
- B. A client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL
- C. A client who was administered adalimumab for Crohn's disease, has a serum calcium level of 10 mg/dL, and reports a headache
- D. A client who was administered acyclovir for cellulitis reports pain in the affected leg
Correct Answer: B
Rationale: The nurse should assess the client who was administered glipizide for type 2 diabetes mellitus and has a blood glucose of 68 mg/dL first. Hypoglycemia (low blood sugar) can lead to serious complications, including confusion, seizures, and loss of consciousness. Immediate intervention is necessary to prevent further deterioration. Choice A could indicate hematuria, which also requires attention but is not immediately life-threatening. Choices C and D do not present immediate life-threatening situations.
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A nurse is planning care for a client who has anorexia nervosa. The nurse should make which of the following client goals the priority?
- A. Identify changes within the family unit that promote the client's autonomy.
- B. Gain 2 pounds of weight per week.
- C. Make positive statements about improvements in body image.
- D. Feel in control of her behavior.
Correct Answer: B
Rationale: The correct answer is B: Gain 2 pounds of weight per week. In anorexia nervosa, the primary goal is to restore the client's weight to a healthy level to prevent serious health complications. Weight restoration is crucial in addressing the physical consequences of severe malnutrition and improving overall health. Gaining weight at a steady pace of 2 pounds per week is a realistic and safe goal.
Other choices are incorrect because:
A: Identifying changes within the family unit is important but not the priority compared to addressing the physical health concerns.
C: Making positive statements about improvements in body image is important for psychological well-being but does not address the immediate health risks associated with anorexia.
D: Feeling in control of behavior is a valid goal, but weight restoration takes precedence due to the critical nature of the client's physical health in anorexia nervosa.
A nurse is reviewing admission assessment and plan of care for a client who has Crohn's disease. Admission Assessment
A 20-year-old admitted through emergency department who is experiencing an exacerbation of previously diagnosed Crohn's disease. Client has lost 6.8 kg (15 lb) over the past week and is too nauseated to keep anything down today. They noticed blood in their stool three days ago. Repeatedly stated to staff, "I do not want to live like this. I am totally frustrated with all you medical people."
Assessment:
Right lower quadrant abdominal pain, abdominal bloating, diarrhea (mucus and blood present), perianal abscess.
Vital Signs:
Temperature 37.5° C (99.5° F)
Heart rate 78/min
Respiratory rate 20/min
Blood pressure 102/54 mm/Hg
Provider Prescriptions
Medical management
CBC, CMP. ESR (erythrocyte sedimentary rate)
MRE (magnetic resonance enterography) of pelvis and abdomen
Corticosteroids for clinical finding management. Taper dose as indicated.
Gastrointestinal evaluation
Nutritional screening and management
Screen for depression
Smoking cessation program
Follow CDC recommended immunizations for those on immunosuppressive therapies.
Evaluate for possible surgical management.
A nurse is reviewing admission assessment and plan of care for a client who has Crohn's disease. Which members of the interdisciplinary team should the nurse anticipate being included the plan of care? Select all that apply.
- A. Occupations Therapist
- B. General Surgeon
- C. Physical Therapist
- D. Radiologist
- E. Registered Dietitian
- F. Gastroenterologist
- G. Speech Therapist
Correct Answer: B,D,E,F
Rationale: The correct answer includes a General Surgeon, Radiologist, Registered Dietitian, and Gastroenterologist. General Surgeon is essential for surgical interventions in severe cases. Radiologist helps in diagnostic imaging. Registered Dietitian assists in managing the client's nutritional needs given the impact of Crohn's disease on digestion. Gastroenterologist specializes in treating gastrointestinal issues like Crohn's disease. The other choices are incorrect because: A) Occupational Therapist primarily focuses on helping individuals engage in meaningful activities, which may not be directly related to managing Crohn's disease. C) Physical Therapist focuses on physical rehabilitation, not the primary focus in managing Crohn's disease. G) Speech Therapist is not typically included in the interdisciplinary team for managing Crohn's disease.
A nurse is teaching a group of newly licensed nurses about client advocacy. Which of the following actions demonstrates client advocacy?
- A. Encouraging a client to participate in treatment decisions.
- B. Administering medications as prescribed without client input.
- C. Documenting a client's refusal of treatment as noncompliance.
- D. Informing the provider that a client is uncooperative.
Correct Answer: A
Rationale: The correct answer is A because encouraging a client to participate in treatment decisions empowers them to make informed choices about their care, promoting their autonomy and self-determination. This demonstrates client advocacy by ensuring the client's voice is heard and respected.
Choice B is incorrect as administering medications without client input disregards their right to be involved in their care decisions. Choice C is incorrect as labeling a client's refusal of treatment as noncompliance lacks advocacy and may undermine the client's autonomy. Choice D is incorrect as simply informing the provider that a client is uncooperative does not actively advocate for the client's best interests or involve them in decision-making.
A charge nurse hears a provider speaking to a staff nurse in anger concerning incorrect supplies that are available to perform a procedure. Which of the following statements by the charge nurse is appropriate?
- A. If you let us know ahead of time that you plan to perform a procedure, we could do better job of having the supplies available.
- B. It must be very frustrating when you don't have want you need to perform the procedure.
- C. I will help you with this procedure instead of the staff nurse.
- D. You should think about how you make others feel when you lose your temper.
Correct Answer: B
Rationale: The correct answer is B because it demonstrates empathy and understanding towards the staff nurse's frustration. By acknowledging the staff nurse's feelings and showing empathy, the charge nurse can diffuse the situation and work towards finding a solution collaboratively.
Choice A is not as appropriate because it may come across as blaming the staff nurse for the lack of supplies. Choice C is not ideal as it doesn't address the underlying issue of the incorrect supplies. Choice D shifts the focus away from the situation at hand and onto the provider's behavior.
In summary, choice B is the best response as it shows empathy, validates the staff nurse's feelings, and opens the door for constructive problem-solving.
A charge nurse is reviewing the list of tasks that have been delegated to the assistive personnel (AP) by the staff nurse. Which of the following tasks should the charge nurse reassign to a licensed nurse?
- A. Providing a back rub to a client who has right-sided paralysis
- B. Transporting a client who experienced a stroke 72 hr ago to the radiology department
- C. Performing oral hygiene for a client who is 1 day postoperative following an amputation of the right arm
- D. Removing and cleaning the cannula of a client who has a new tracheostomy
Correct Answer: D
Rationale: The correct answer is D because removing and cleaning the cannula of a client with a new tracheostomy requires specialized skills and knowledge that only a licensed nurse possesses to prevent complications and ensure safety. Providing a back rub (A) can be delegated to an AP as it is within their scope of practice. Transporting a stroke client (B) and performing oral hygiene post-amputation (C) can also be delegated as they do not involve complex nursing assessments or interventions. It is crucial to reassign the tracheostomy care task to a licensed nurse to maintain the client's airway safely.