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A nurse is caring for a client who has given informed consent for electroconvulsive therapy. Just before the procedure, the client tells the nurse she is considering not going forward with the treatment. Which of the following statements by the nurse is appropriate?
- A. Most people who have this procedure feel better following the treatment.
- B. Your doctor wouldn't have ordered this treatment unless it was necessary.â€
- C. It's okay to be nervous before this treatment.
- D. You don't have to go through with the treatment.
Correct Answer: D
Rationale: Rationale: Option D is correct because it respects the client's autonomy and right to make decisions about their treatment. The client has the right to refuse treatment, even after giving initial consent. It is important for the nurse to support the client's decision without coercion.
Summary:
A: Incorrect. This statement does not address the client's current decision to refuse treatment.
B: Incorrect. This statement undermines the client's autonomy by implying they should follow the doctor's orders.
C: Incorrect. While acknowledging the client's feelings is important, it does not address the client's decision to refuse treatment.
D: Correct. Respects the client's autonomy and decision-making.
E, F, G: Not applicable.
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A nurse is obtaining a client's manual blood pressure and is having difficulty auscultating sounds.
Which of the following actions should the nurse take?
- A. Use the palpatory method to determine blood pressure
- B. Place the arm above the level of the client's heart.
- C. Apply the largest cuff available.
- D. Deflate the cuff quickly.
Correct Answer: A
Rationale: The palpatory method can help obtain a more accurate reading when sounds are difficult to auscultate.
A charge nurse on a medical-surgical unit is assisting with the emergency response plan following an external disaster in the community, In anticipation of multiple client admissions,
Which of the following current clients should the nurse recommend for early discharge?
- A. A client who is receiving heparin for deep- vein thrombosis
- B. A client who has COPD and a respiratory rate of 44/min
- C. A client who has cancer and a sealed implant for radiation therapy
- D. A client who is 1 day postoperative following a vertebroplasty
Correct Answer: D
Rationale: Stable postoperative clients can be discharged safely.
A nurse is caring for a newborn. Vital Signs 0640: Temperature 36.7° C(98.1° F) axillary Heart rate 154/min Respiratory rate 68/min BP 72/48 mm Hg 0650: Heart rate 156/min Respiratory rate 72/min 0700: Temperature 37° C(98.6° F) axillary Heart rate 156/min Respiratory rate 76/min Admission Assessment 0630: Newborn delivered via cesarean birth under spinal anesthesia at 0630. Amniotic fluid clear 0631: 1-min Apgar score 7 0536 5-min Apgar score 9 Newborn transferred to nursery Nurses' Notes 0640: Weight 4200 gm(9 ib 4 oz, head circumference 35.5 cm(14 in) Respiratory rate 68/min, with mild grunting 0650: Respiratory rate 72/min, with mild grunting 0700: Respiratory rate 76/min, with moderate grunting and mild intercostal retractions
The client is at risk for developing ------- and--------
- A. Hypoglycemia
- B. bronchopulmonary dysplasia
- C. transient tachypnea of the newborn
- D. Tachycardia
Correct Answer: A, C
Rationale: The correct answer is A and C. Hypoglycemia and transient tachypnea of the newborn are common risks for newborns. Hypoglycemia can occur due to immature liver function, while transient tachypnea results from retained lung fluid. The other choices are incorrect because bronchopulmonary dysplasia is a chronic lung condition seen in premature infants, and tachycardia is a symptom of various conditions but not typically a primary risk for newborns.
A nurse is caring for a client in a clinic.
Based on the information in the client's medical record, which of the following findings require immediate follow-up? Select the 4 findings that require follow-up.
- A. Smoking marijuana to clear their mind
- B. Attends school regularly
- C. Heart rate 99/min
- D. Client experiences nightmares
- E. BP 122/80 mm Hg
- F. Caregiver reporting client acting differently than usual
- G. Witnessing their family's death
Correct Answer: A,D,F,G
Rationale: These findings suggest unresolved trauma and substance use, requiring intervention.
A nurse is teaching a client who has atrial fibrillation and is to start taking dabigatran.
Which of the following statements by the client indicates an understanding of the teaching?
- A. I should keep the medication in the original container.
- B. I should replace any unused medication every 6 months.
- C. I can store the medication in the refrigerator.
- D. I can crush the medication and mix with applesauce.
Correct Answer: A
Rationale: The correct answer is A because keeping medication in the original container ensures proper identification, dosage, and expiration monitoring. Choice B is incorrect as replacing unused medication every 6 months may lead to waste. Choice C is incorrect as not all medications should be stored in the refrigerator. Choice D is incorrect as crushing medication may alter its effectiveness or cause harm. It is important for the client to understand the importance of following specific storage instructions provided with the medication, making choice A the most appropriate response.