Nokea
A nurse is caring for a client diagnosed with Trigeminal neuralgia who is suddenly experiencing severe pain on the left side of the face. The nurse identifies which classification of medications is most effective in treating this type of pain?
- A. Analgesics
- B. Antibiotics
- C. Anticonvulsants
- D. Antihistamines
Correct Answer: C
Rationale: The correct answer is C: Anticonvulsants. Trigeminal neuralgia is a neuropathic pain disorder, and anticonvulsants like carbamazepine are the first-line treatment due to their ability to stabilize nerve cell membranes and reduce pain signals. Analgesics (choice A) may not be effective for neuropathic pain. Antibiotics (choice B) are used to treat infections, not neuropathic pain. Antihistamines (choice D) are used for allergies and not indicated for treating trigeminal neuralgia.
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The nurse is preparing for an initial home care visit for a client with diabetes. Which action by the nurse is appropriate? SELECT ALL THAT APPLY
- A. Going automatically into the client's bedroom
- B. Thanking the client for arranging a home visit
- C. Arranging mutual future visits
- D. Asking how they are managing at home
- E. Sitting down and discussing with the client and family members
Correct Answer: C,D,E
Rationale: The correct actions (C, D, E) are appropriate for the initial home care visit for a client with diabetes. C is correct because arranging mutual future visits establishes continuity of care. D is correct since asking about home management helps assess the client's self-care abilities. E is essential as it promotes open communication and involvement of the client and family in the care plan. A is incorrect as entering the client's bedroom without permission violates privacy. B is incorrect as it is general politeness and not specific to diabetes care.
A nurse is providing education regarding biologic threats. When discussing anthrax, which of the following should be included as potential portals of entry? SELECT ALL THAT APPLY
- A. Central nervous system
- B. Integumentary system
- C. Respiratory system
- D. Renal system
- E. Gastrointestinal system
Correct Answer: B,C,E
Rationale: The correct answer includes the integumentary system (B), respiratory system (C), and gastrointestinal system (E) as potential portals of entry for anthrax. Anthrax can enter the body through broken skin (integumentary system), inhalation of spores (respiratory system), or ingestion of contaminated food/water (gastrointestinal system). The central nervous system (A) and renal system (D) are not typical routes of entry for anthrax. Central nervous system is not a common portal for anthrax entry, and the renal system is not a primary site for anthrax spore invasion.
A nurse is caring for a client brought to the Emergency Department as one of the first victims of a train accident. The nurse assesses the client, noting a respiratory rate of 38, a weak, rapid pulse, and uncontrolled bleeding. Using NATO guidelines, the nurse assigns which priority tag?
- A. Red tag
- B. Black tag
- C. Green tag
- D. Yellow tag
Correct Answer: A
Rationale: The correct answer is A: Red tag. The nurse assigns a red tag based on the assessment findings of a high respiratory rate, weak rapid pulse, and uncontrolled bleeding, indicating a critically injured patient requiring immediate intervention. Red tag signifies priority 1 according to NATO guidelines, indicating the need for immediate life-saving interventions. Other choices are incorrect because Black tag (B) is used for deceased or non-salvageable patients, Green tag (C) for minor injuries, and Yellow tag (D) for delayed or non-urgent care. In this scenario, the patient's critical condition necessitates the assignment of a red tag for prompt and urgent care.
A nurse is conducting triage of clients transported from a mass casualty incident (MCI). A client arrives saturated with an unknown substance and medical transport reports feeling dizzy. The nurse should prioritize which actions? SELECT ALL THAT APPLY
- A. Assign the client to a private room
- B. Remove client and transport crew from the Emergency department
- C. Contact decontamination team
- D. Call the scene to identify the chemical
- E. Immediately remove the saturated clothing from the client
Correct Answer: B,C,E
Rationale: Correct Answer: B, C, E
Rationale:
1. Option B - Removing the client and transport crew from the Emergency department is crucial to prevent potential contamination of others and ensure safety.
2. Option C - Contacting the decontamination team is essential to properly manage and decontaminate the client and the area.
3. Option E - Removing the saturated clothing from the client immediately helps eliminate further exposure and contamination risks.
Incorrect Answers:
A: Assign the client to a private room - This is not the priority as immediate decontamination and safety measures are needed.
D: Call the scene to identify the chemical - Identifying the substance is important but not the priority when the client's safety is at risk.
A nurse is delegating tasks to the assistive personnel (AP). The nurse should direct the AP to complete which of the following tasks first?
- A. Assisting a client with a bed bath who has a history of falls
- B. Providing a snack to a diabetic client who is feeling lightheaded
- C. Feeding a client who has bilateral casts due to upper arm fractures
- D. Ambulating a postoperative client for the first time
Correct Answer: B
Rationale: The correct answer is B because providing a snack to a diabetic client who is feeling lightheaded addresses an immediate physiological need. Hypoglycemia can lead to serious complications and needs to be addressed promptly to prevent harm. Choices A, C, and D involve important tasks but do not address an urgent physiological need like hypoglycemia. Assisting a client with a bed bath, feeding a client with bilateral casts, or ambulating a postoperative client can be prioritized based on the client's condition and safety but do not take precedence over addressing a potential medical emergency like hypoglycemia.