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.
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A nurse in a dialysis center is caring for a client who has a new diagnosis of end-stage renal disease. At the first dialysis treatment, the client tells the nurse, 'I decided to come today, but I am not sure if I will need to come back again this week. I am feeling much better since my discharge from the hospital and I think my kidneys are working again.' The nurse should recognize the client is demonstrating which stage of Kübler-Ross's stages of grieving?
- A. Bargaining
- B. Denial
- C. Depression
- D. Anger
Correct Answer: B
Rationale: The correct answer is B: Denial. The client's statement indicates denial as they are refusing to accept the reality of their condition and are hopeful that their kidneys are functioning again, despite the need for dialysis. This stage in Kübler-Ross's stages of grieving involves avoiding the truth to cope with the overwhelming emotions. Bargaining (A), Depression (C), and Anger (D) are not demonstrated in the client's statement. Bargaining involves seeking alternatives to the situation, Depression involves feelings of sadness and hopelessness, and Anger involves frustration and resentment.
A nurse is caring for a client who had a severe traumatic brain injury 3 weeks ago, remains unconscious, and is unlikely to recover. While bathing the client, the assistive personnel (AP) talks to him about current events. The client's partner asks the nurse why the AP talks to the client. Which of the following responses should the nurse make?
- A. I'm really not sure why the assistant is talking to him. Perhaps you should ask her.
- B. Although your partner is not responding to us, he might still be able to hear.
- C. Don't let that concern you. She talks to all her clients, no matter what.
- D. She is an excellent caregiver. She has many others to care for, but she takes the time to talk to your partner.
Correct Answer: B
Rationale: The correct answer is B: Although your partner is not responding to us, he might still be able to hear. This response is correct because research shows that comatose patients can still hear and process information. Talking to the patient can provide comfort, familiarity, and potentially stimulate brain activity.
Choices A, C, and D are incorrect because they do not address the potential benefit of talking to the unconscious patient. A deflects the question, C generalizes the behavior, and D praises the caregiver without explaining the rationale behind talking to the patient.
In summary, choice B is the best response as it acknowledges the potential for the unconscious patient to hear and emphasizes the importance of continuing communication for the patient's well-being.
A nurse is assisting with the preparation of a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device to help clients learn to control physical responses?
- A. Reiki
- B. Biofeedback
- C. Acupuncture
- D. Yoga
Correct Answer: B
Rationale: Biofeedback uses electronic monitoring to help individuals gain control over physiological functions such as heart rate and muscle tension.
A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to thin the client's respiratory secretions?
- A. Encourage the client to ambulate more often.
- B. Encourage coughing and deep breathing.
- C. Encourage the client to drink more fluids.
- D. Encourage regular use of the incentive spirometer.
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to drink more fluids. Increased fluid intake helps to thin respiratory secretions, making it easier for the client to cough them up and clear the airways. This action promotes effective airway clearance and reduces the risk of complications such as pneumonia worsening. Encouraging ambulation (A) is beneficial for overall lung health but does not directly address thinning of respiratory secretions. While coughing and deep breathing (B) are important for clearing secretions, increasing fluids is more effective in thinning them. Using the incentive spirometer (D) helps with lung expansion but does not directly thin secretions.
A nurse is collecting data from a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Muscle distortion
- B. Pain behind the ear
- C. Hearing loss
- D. Facial twitching
- E. Impaired taste
Correct Answer: A,B,E
Rationale: The correct findings for a client with Bell's palsy are muscle distortion, pain behind the ear, and impaired taste. Muscle distortion occurs due to facial nerve paralysis, leading to drooping or weakness on one side of the face. Pain behind the ear can result from inflammation of the facial nerve. Impaired taste can occur due to dysfunction of the taste buds innervated by the facial nerve. Hearing loss (C) is not typically associated with Bell's palsy. Facial twitching (D) may occur in other conditions like hemifacial spasm but not a defining feature of Bell's palsy.