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A nurse is caring for a client who has an altered mental status and has become aggressive. Which of the following prescriptions should the nurse clarify with the provider prior to administration?
- A. Haloperidol
- B. Zolpidem
- C. Morphine
- D. Lorazepam
Correct Answer: B
Rationale: The correct answer is B: Zolpidem. Zolpidem is a sedative-hypnotic medication that can worsen altered mental status, especially in clients who are already aggressive. Therefore, the nurse should clarify this prescription with the provider before administration to ensure it is safe for the client.
Choice A, Haloperidol, is an antipsychotic commonly used to manage aggression in clients with altered mental status, making it an appropriate choice in this scenario. Choice C, Morphine, is an opioid analgesic and would not directly impact the client's altered mental status or aggression. Choice D, Lorazepam, is a benzodiazepine used to manage anxiety and agitation, which could be beneficial in this situation but does not have the same potential to exacerbate altered mental status as Zolpidem.
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What are the differences between viral and bacterial infections?
- A. Viral infections often cause fatigue and body aches
- B. Bacterial infections often cause high fever and localized pain
- C. Viral infections are treated with antibiotics
- D. Bacterial infections are usually self-limiting
Correct Answer: A
Rationale: Corrected Rationale: Viral infections often cause fatigue and body aches, while bacterial infections are more likely to cause high fever and localized pain. Choice A is the correct answer as it accurately reflects the symptoms commonly associated with viral infections. Bacterial infections, on the other hand, typically present with fever and localized pain, as stated in choice B. Choice C is incorrect as viral infections do not respond to antibiotics, while choice D is inaccurate because bacterial infections may require antibiotic treatment and are not always self-limiting.
What are key signs of a urinary tract infection (UTI) in older adults?
- A. Confusion and increased temperature
- B. Painful urination and frequent urination
- C. Dizziness and headache
- D. Back pain and fever
Correct Answer: A
Rationale: The correct answer is A. In older adults, key signs of a UTI often include confusion and increased temperature. Confusion is a common symptom in the elderly when they have a UTI, and an increase in body temperature can indicate an infection. Choices B, C, and D are incorrect because while painful urination and frequent urination are common UTI symptoms in general, they may not be as prominent in older adults. Dizziness, headache, back pain, and fever can be associated with other conditions but are not typically key signs of a UTI in older adults.
The nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?
- A. Request an occupational therapy consult to determine the need for assistive devices
- B. Assign assistive personnel to perform self-care tasks for the client
- C. Instruct the client to focus on gradually resuming self-care tasks
- D. Ask the client if a family member is available to assist with his care
Correct Answer: C
Rationale: Instructing the client to focus on gradually resuming self-care tasks is the most appropriate strategy to promote independence while managing fatigue. This approach encourages the client to regain autonomy by engaging in self-care activities at their own pace. Requesting an occupational therapy consult (Choice A) may be beneficial but does not directly address the client's concern regarding fatigue and self-care. Assigning assistive personnel (Choice B) may hinder the client's independence by taking over tasks the client could potentially perform. Asking about family assistance (Choice D) does not empower the client to regain self-care abilities.
What are the key nursing interventions for a patient undergoing dialysis?
- A. Monitor fluid balance and administer heparin
- B. Monitor blood pressure and prevent clot formation
- C. Administer medications and monitor blood chemistry
- D. Provide dietary education and encourage protein intake
Correct Answer: A
Rationale: The correct answer is A: Monitor fluid balance and administer heparin. For a patient undergoing dialysis, it is crucial to monitor fluid balance to prevent fluid overload or depletion. Administering heparin helps prevent clot formation during the dialysis process. Option B is incorrect as while monitoring blood pressure is essential, preventing clot formation is more directly related to heparin administration. Option C is incorrect because administering medications and monitoring blood chemistry are not the primary interventions for dialysis. Option D is incorrect as while dietary education and protein intake are important for overall health, they are not the key nursing interventions specifically for a patient undergoing dialysis.
A nurse is caring for a client following an acute myocardial infarction who is concerned about fatigue. What is the best strategy to promote independence in self-care?
- A. Instruct the client to remain in bed until the fatigue resolves
- B. Encourage the client to gradually resume self-care tasks with frequent rest periods
- C. Assign assistive personnel to perform all self-care tasks for the client
- D. Ask the client's family to assist with self-care
Correct Answer: B
Rationale: Encouraging the client to gradually resume self-care tasks with frequent rest periods is the best strategy to promote independence while managing fatigue. This approach allows the client to regain confidence in their abilities and fosters independence. Option A is incorrect as prolonged bed rest can lead to deconditioning and worsen fatigue. Option C is not promoting independence as it involves delegating all self-care tasks to others. Option D involves family assistance, which may be helpful but does not directly promote the client's independence in self-care.