Nokea
A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. While the client waits for the x-ray technician, which of the following actions should the nurse take? (Select all that apply.)
- A. Apply ice to the ankle.
- B. Encourage range-of-motion exercises of the foot.
- C. Provide the client with a light snack.
- D. Apply a compression bandage.
- E. Elevate the foot.
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
- Apply ice to the ankle (A): Ice helps reduce swelling and inflammation by constricting blood vessels. It is essential for reducing pain and promoting healing.
- Apply a compression bandage (D): Compression helps reduce swelling and provides support to the injured area, promoting healing and preventing further damage.
- Elevate the foot (E): Elevating the foot above the heart level helps reduce swelling and promotes circulation, aiding in the healing process.
Incorrect Choices:
- Encourage range-of-motion exercises of the foot (B): Performing range-of-motion exercises on an injured ankle may worsen the injury and cause further damage.
- Provide the client with a light snack (C): Providing a snack is not a priority in this situation and does not contribute to the client's immediate care.
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A nurse is caring for four clients who have drainage tubes. The nurse should identify the client who has which of the following tubes as being at risk for hypokalemia?
- A. An NG tube to suction
- B. An indwelling urinary catheter to gravity drainage
- C. A chest tube to water-seal drainage
- D. A nephrostomy tube to a drainage bag
Correct Answer: A
Rationale: NG suction removes gastric contents, leading to loss of potassium and increased risk of hypokalemia.
A nurse notes that the left eyelid of a client who is unconscious remains partially open. To protect the eye, which of the following actions should the nurse take?
- A. Irrigate the eye daily with 0.9% sodium chloride irrigation solution.
- B. Dim the lights in the room.
- C. Instill ophthalmic ointment into the lower lid.
- D. Keep the client off her left side.
Correct Answer: C
Rationale: The correct answer is C: Instill ophthalmic ointment into the lower lid. This action helps prevent corneal abrasions by keeping the eye moist and lubricated. Irrigating the eye with saline solution (choice A) may not provide adequate protection. Dimming the lights (choice B) doesn't directly address eye protection. Keeping the client off her left side (choice D) is unrelated to eye care.
A nurse is caring for a client whose parent has died. The client asks the nurse, 'Why do I feel relief now that my dad is gone?' Which of the following responses should the nurse make?
- A. You should start planning your father's funeral.'
- B. Tell me what you are thinking.'
- C. You are in denial about your father's death.'
- D. Your father is not suffering anymore.'
Correct Answer: B
Rationale: Encouraging the client to express their feelings fosters therapeutic communication and helps with grief processing.
A nurse is caring for several clients at various developmental stages. The nurse understands that according to Erikson, acceptance of death occurs at which of the following stages of psychosocial development?
- A. Autonomy vs. Shame and Doubt
- B. Generativity vs. Stagnation
- C. Identity vs. Role Diffusion
- D. Integrity vs. Despair
Correct Answer: D
Rationale: The correct answer is D: Integrity vs. Despair. According to Erikson's psychosocial development theory, acceptance of death occurs during the final stage of life, which is Integrity vs. Despair. In this stage, individuals reflect on their lives and come to terms with their mortality, finding a sense of fulfillment and wisdom. Option A (Autonomy vs. Shame and Doubt) focuses on developing a sense of independence in early childhood. Option B (Generativity vs. Stagnation) pertains to middle adulthood and concerns contributing to society and future generations. Option C (Identity vs. Role Diffusion) relates to adolescence and the formation of a sense of self. These stages do not specifically address acceptance of death.
A nurse is assisting with the admission of a client to an inpatient unit. Which of the following sources of information should the nurse use as a primary source of accurate data about the client?
- A. Client concerns
- B. Family information
- C. Medical history
- D. Progress notes
Correct Answer: A
Rationale: The correct answer is A: Client concerns. The primary source of accurate data about the client should always be the client themselves. Clients are the most reliable sources of information regarding their own health, symptoms, and preferences. By directly asking the client about their concerns, the nurse can gather accurate and firsthand information. Family information (B) may be helpful but may not always be completely accurate. Medical history (C) and progress notes (D) are important sources of information but may not always reflect the client's current status or concerns. It is crucial to prioritize the client's perspective to ensure personalized and effective care.