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A nurse in a provider's office is caring for a client who asks about using acupuncture to manage his osteoarthritis pain. The nurse should identify which of the following conditions as a contraindication for receiving this treatment?
- A. Hypertension
- B. Obesity
- C. Hypothyroidism
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. Acupuncture involves inserting needles into specific points on the body to alleviate pain. Herpes zoster, also known as shingles, is a viral infection that causes a painful rash. The presence of open sores or active infection in the area where acupuncture needles would be inserted can lead to complications such as spreading the virus or causing pain. Therefore, it is contraindicated to receive acupuncture treatment when a client has active herpes zoster.
Hypertension (A), obesity (B), and hypothyroidism (C) are not contraindications for acupuncture treatment. Hypertension may actually benefit from acupuncture as it can help reduce stress and improve circulation. Obesity and hypothyroidism do not pose any direct risks for receiving acupuncture treatment.
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A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
- A. A client who has epidural analgesia and weakness in the lower extremities.
- B. A client who has a hip fracture and a new onset of tachypnea.
- C. A client who has sinus arrhythmia and is receiving cardiac monitoring.
- D. A client who has diabetes mellitus and an HbA1C of 6.8%.
Correct Answer: B
Rationale: The correct answer is B because a client with a hip fracture and new onset of tachypnea may have a pulmonary embolism, a life-threatening complication that requires immediate assessment and intervention. Tachypnea can indicate hypoxia, which can be fatal if not addressed promptly. The nurse should prioritize assessing this client to ensure timely management and prevent further deterioration.
Clients A, C, and D do not present with immediate life-threatening conditions that require urgent assessment compared to client B. Client A's weakness in the lower extremities, client C's sinus arrhythmia, and client D's HbA1C level do not pose immediate risks to their health. Therefore, the nurse should assess client B first to address the potential pulmonary embolism.
A nurse is caring for a client who has been admitted to the hospital. Select the 5 actions the nurse should take?
- A. Provide frequent rest periods for the client
- B. Restrict the client's sodium intake
- C. Advise the client to avoid the use of soap and alcohol-based lotions.
- D. Place the client on a low-carbohydrate diet
- E. Instruct the client to avoid blowing their nose forcefully
- F. Assess the client's level of orientation.
Correct Answer: A,B,C,E,F
Rationale: The correct actions for the nurse to take are A, B, C, E, and F. Providing rest periods (A) promotes healing and recovery. Restricting sodium intake (B) is important for certain conditions like hypertension. Advising the client to avoid soap and alcohol-based lotions (C) can prevent skin irritation. Instructing the client to avoid blowing their nose forcefully (E) prevents potential harm to nasal passages. Assessing the client's level of orientation (F) is crucial for monitoring mental status and detecting any changes. These actions prioritize the client's well-being, safety, and overall health.
The nurse is planning care for the client. Which of the following prescriptions should the nurse anticipate the provider to prescribe?
- A. Limit alcohol intake to two drinks per day.
- B. Keep daily fat intake to less than 35%.
- C. Administer an antibiotic medication.
- D. Place on 2,300 mg sodium diet.
- E. Administer an antihypertensive medication.
- F. Limit foods high in potassium.
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. A - Limiting alcohol intake reduces the risk of adverse health effects. D - A 2,300 mg sodium diet is beneficial for managing blood pressure. E - Antihypertensive medication helps control high blood pressure. B and F are not directly related to planning care for the client. C may not be necessary unless there is an infection present.
A nurse is caring for a client who is expressing anger about his diagnosis of colorectal cancer. Which of the following actions should the nurse take?
- A. Discuss the risk factors for colon cancer.
- B. Focus teaching on what the client will need to do in the future to manage his illness.
- C. Provide the client with written information about the phases of loss and grief.
- D. Reassure the client that this is an expected response to grief.
Correct Answer: D
Rationale: The correct answer is D: Reassure the client that this is an expected response to grief. By reassuring the client that feeling anger about the diagnosis of colorectal cancer is a normal part of the grieving process, the nurse acknowledges the client's emotions and validates their experience. This can help the client feel understood and supported, fostering a therapeutic relationship. Discussing risk factors (A) may not address the client's current emotional needs. Teaching future management (B) may be premature as the client is currently expressing anger. Providing written information on loss and grief phases (C) may not directly address the client's anger. Therefore, the best immediate action is to validate the client's emotions and offer reassurance (D).
A nurse is assessing a client immediately following a cardiac catheterization. The nurse should notify the provider for which of the following findings?
- A. Report of discomfort at the insertion site
- B. Heart rate 90/min
- C. Bounding pulses in the affected extremity
- D. Hematoma over the insertion site
Correct Answer: C
Rationale: The correct answer is C: Bounding pulses in the affected extremity. Bounding pulses can indicate arterial occlusion or other circulatory complications post-cardiac catheterization, requiring immediate intervention. A: Discomfort at the insertion site is expected and can be managed with pain medication. B: Heart rate of 90/min is within normal range. D: Hematoma over the insertion site is common after the procedure and may resolve on its own.