Nokea
A nurse is assisting a client during ambulation when the client begins to fall. Which of the following actions should the nurse take?
- A. Provide support by holding the client's arm.
- B. Lean the client toward the wall.
- C. Lower the client to the floor.
- D. Maintain a narrow base of support.
Correct Answer: C
Rationale: The correct action for the nurse to take when a client begins to fall during ambulation is to lower the client to the floor (Choice C). This is the safest option to prevent further injury to the client. Lowering the client to the floor helps minimize the distance of the fall, reducing the risk of serious injury. Additionally, it allows for a controlled descent, ensuring the client lands safely. Providing support by holding the client's arm (Choice A) may not be enough to prevent a fall and could lead to both the nurse and the client getting injured. Leaning the client toward the wall (Choice B) may not provide adequate support and could still result in a fall. Maintaining a narrow base of support (Choice D) may not be effective in preventing a fall. The best course of action is to prioritize the safety of the client by lowering them to the floor in a controlled manner.
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When a nurse obtains an unusually low blood pressure measurement for a client whose blood pressure is generally elevated, she considers the possibility of a problem with her technique. Which of the following sources of error should she consider as a possible cause of the low reading?
- A. Wrapping the cuff too loosely around the client's arm
- B. Positioning the client's arm above heart level
- C. Measuring blood pressure right after the client's mealtime
- D. Deflating the cuff too slowly
Correct Answer: B
Rationale: The correct answer is B: Positioning the client's arm above heart level. When the client's arm is positioned above heart level, it can lead to an artificially low blood pressure reading due to gravitational effects. This position can cause blood to pool in the arm, reducing the pressure in the arteries and resulting in an inaccurate measurement. This error is known as hydrostatic pressure error. Wrapping the cuff too loosely (choice A) can lead to an inaccurate reading due to inadequate compression of the artery. Measuring blood pressure right after a meal (choice C) can also affect the reading due to the body's response to food intake. Deflating the cuff too slowly (choice D) can result in a falsely elevated diastolic reading.
A nurse is assisting with the care of a client who has developed cardiogenic shock. When evaluating circulation to the client's brain, which of the following pulse sites should the nurse use?
- A. Femoral
- B. Carotid
- C. Popliteal
- D. Radial
Correct Answer: B
Rationale: The correct answer is B: Carotid. The carotid pulse site should be used when assessing circulation to the brain in a client with cardiogenic shock because it is the closest pulse site to the brain. The carotid artery supplies blood directly to the brain, making it the most accurate site to assess perfusion to this vital organ.
A: Femoral, C: Popliteal, and D: Radial are not ideal pulse sites for assessing circulation to the brain in a client with cardiogenic shock because they are further away from the brain compared to the carotid artery. Using these sites may not provide an accurate representation of cerebral perfusion in this critical situation.
A nurse is caring for a client whose belongings were lost in a hurricane. The client says, 'What's the use in starting over? It will probably happen again.' Which of the following responses should the nurse make?
- A. I am sure everything will work out.'
- B. It appears you are feeling hopeless.'
- C. It is probably not as bad as you think.'
- D. I would not worry about what can't be changed.'
Correct Answer: B
Rationale: Acknowledging feelings of hopelessness is therapeutic and encourages the client to express emotions.
A nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. When collecting data from this client, the nurse should expect to find which of the following early indications of hypoxia?
- A. Bradypnea
- B. Peripheral edema
- C. Cyanosis
- D. Hypertension
Correct Answer: D
Rationale: Early signs of hypoxia include tachypnea, restlessness, and hypertension due to sympathetic nervous system activation.
A nurse is caring for a client whose partner asks to speak with the nurse. The client's partner relates that she is concerned because her partner abuses alcohol and has difficulty maintaining employment. Which of the following responses should the nurse make?
- A. If I were you, I would contact a support group.
- B. I'm so sorry to hear about this.
- C. I suggest you talk with the hospital chaplain about your concern.
- D. What have you done in the past to cope with this issue?
Correct Answer: D
Rationale: Exploring the partner's past coping strategies encourages problem-solving and emotional support.