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A nurse is admitting a patient exhibiting manic behavior. The patient reports recent personal stressors, including the loss of her mother and a divorce. What should be the nurse's priority action? What is the priority action for a manic patient?
- A. Encourage self-care.
- B. Assist the patient in identifying coping behaviors.
- C. Prevent self-directed violence.
- D. Identify support systems.
Correct Answer: C
Rationale: The correct answer is C: Prevent self-directed violence. When dealing with a manic patient, the priority action should always be to ensure the safety of the patient and others. Manic episodes can lead to impulsive and risky behaviors, including self-harm or suicide attempts. By prioritizing the prevention of self-directed violence, the nurse can address the immediate threat to the patient's well-being. Encouraging self-care (choice A) and identifying coping behaviors (choice B) are important aspects of care but may not be the most urgent in this situation. Identifying support systems (choice D) is also valuable but does not address the immediate safety concerns presented by the manic behavior.
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Nurses’ Notes at 0700hrs
The client appears fatigued and reports a persistent headache. He has been experiencing muscle aches throughout his body. He also complains of a sore throat and has had a fever for the past two days. The client’s skin is warm to the touch and he appears slightly dehydrated.
Vital Signs at 0700hrs
• Temperature: 39.5°C (103.1°F)
• Blood pressure: 128/56 mm Hg
• Heart rate: 112/min
• Respiratory rate: 22/min
• SaO2: 96% on room air
Diagnostic Results at 0700hrs
• Complete blood count shows elevated white blood cells
• Throat culture has been sent to the lab for analysis
• Chest X-ray pending
A nurse is caring for a 45-year-old male client in the emergency department. The client was admitted at 0700hrs with a 2-day history of headache, muscle aches, fever, sore throat, and fatigue.The nurse is preparing to administer an antibiotic to the client. Which of the following actions should the nurse take? (Select all that apply)
- A. Wear a mask when caring for the client.
- B. Encourage the client to increase fluid intake.
- C. Place the client in a private room.
- D. Place the client on contact precautions.
- E. Monitor the client's temperature every 4 hours.
- F. Check the client's allergy history before administering the antibiotic.
- G. Educate the client about the importance of completing the full course of antibiotics.
Correct Answer: B,E,F,G
Rationale: The correct actions the nurse should take are to encourage the client to increase fluid intake, monitor the client's temperature every 4 hours, check the client's allergy history before administering the antibiotic, and educate the client about the importance of completing the full course of antibiotics.
Encouraging fluid intake helps maintain hydration and aids in the body's recovery. Monitoring temperature helps assess the client's response to treatment. Checking allergy history is crucial to prevent adverse reactions. Educating the client about completing the full course of antibiotics ensures effective treatment and prevents antibiotic resistance.
Wearing a mask (choice A) is not necessary for this situation unless the client is suspected of having a contagious respiratory illness. Placing the client in a private room (choice C) and placing the client on contact precautions (choice D) are not indicated unless the client is diagnosed with a specific contagious infection, which is not mentioned in the scenario.
A nurse is caring for a patient who is receiving total parenteral nutrition (TPN). Which of the following laboratory values should the nurse monitor? Which lab value should the nurse monitor for TPN?
- A. Serum glucose
- B. Serum calcium
- C. Serum magnesium
- D. Serum sodium
Correct Answer: A
Rationale: The correct answer is A: Serum glucose. When a patient is receiving TPN, monitoring serum glucose levels is crucial as TPN solutions contain high concentrations of glucose. Elevated glucose levels can lead to hyperglycemia, which can result in complications such as osmotic diuresis and hyperosmolar hyperglycemic state. Monitoring glucose levels helps in adjusting TPN infusion rates to maintain a stable blood glucose level.
Incorrect answers:
B: Serum calcium - Calcium levels are not directly affected by TPN and are not typically monitored specifically for patients receiving TPN.
C: Serum magnesium - While magnesium levels may be affected by TPN, glucose monitoring is more critical due to the high glucose content in TPN.
D: Serum sodium - Sodium levels are not directly influenced by TPN and are not typically monitored specifically for patients receiving TPN.
A nurse is preparing to administer furosemide 40 mg IV. Available is furosemide 10 mg/1 mL. How many mL should the nurse administer per dose? How many mL of furosemide should the nurse administer?
Correct Answer: 4
Rationale: The correct answer is 4 mL. To determine this, the nurse uses the formula: Desired dose (40 mg) ÷ Stock strength (10 mg/1 mL) = mL to administer. Thus, 40 mg ÷ 10 mg/1 mL = 4 mL. This calculation ensures the proper dosage is given. Other choices are incorrect because they do not follow the correct dosage calculation based on the given information.
A nurse is calculating the total fluid intake for a patient over a 4-hour period. The patient consumed 1 cup of coffee, 4 oz of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3 oz of water. How many mL of intake should the nurse record on the patient's chart? How many mL of fluid intake should the nurse record?
Correct Answer: 1160
Rationale: The correct answer is 1160 mL. To calculate this, first convert all measurements to mL: 1 cup = 240 mL, 1 oz = 30 mL.
Coffee (240 mL), orange juice (120 mL), water (90 mL), flavored gelatin (240 mL), tea (240 mL), broth (150 mL), water (90 mL).
Adding these up: 240 + 120 + 90 + 240 + 240 + 150 + 90 = 1170 mL.
Therefore, the nurse should record 1160 mL on the patient's chart.
Other choices are incorrect because they do not calculate the total accurately or convert all measurements to mL.
A nurse is instructing a patient who has been newly prescribed sumatriptan tablets for the treatment of migraine headaches. Which instructions should the nurse include? What instructions should the nurse include for sumatriptan?
- A. Report any eyelid swelling after dosage.
- B. Repeat the dose in 1 hour if the headache persists.
- C. Take the medication daily to prevent headaches.
- D. Thoroughly chew the tablet before swallowing.
Correct Answer: B
Rationale: The correct answer is B: Repeat the dose in 1 hour if the headache persists. Sumatriptan is used to treat acute migraine attacks, and the patient should be instructed to take a second dose if the headache does not improve after the first dose. This is important because it helps ensure adequate relief of symptoms. Choices A and D are incorrect because eyelid swelling is not a common side effect of sumatriptan, and sumatriptan tablets should be swallowed whole without chewing. Choice C is incorrect because sumatriptan is not taken daily for headache prevention; it is used as needed for acute migraine attacks.