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A nurse is caring for a client who questions the need for cardiac rehabilitation, stating, 'My heart is permanently damaged from the heart attack, so what's the point of cardiac rehabilitation?' Which response should the nurse prioritize?
- A. It's not unusual to feel that way at first, but once you learn the routine, you'll enjoy it
- B. Diet and exercise are good for you and good for your heart
- C. Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely
- D. Your doctor is the expert here, and I'm sure they would only recommend what is best for you
Correct Answer: C
Rationale: The correct answer is C: Cardiac rehabilitation cannot undo the damage to your heart but it can help you get back to your previous level of activity safely. This response prioritizes providing the client with accurate information and managing expectations. It acknowledges the client's concern about the permanent damage to the heart but also emphasizes the benefits of cardiac rehabilitation in improving overall function and quality of life. It is essential for the nurse to address the client's misconceptions and provide education on the purpose and benefits of cardiac rehabilitation.
Choice A is incorrect as it focuses more on the client's emotional response rather than providing factual information. Choice B is too general and does not directly address the client's specific concerns. Choice D shifts the responsibility to the doctor without addressing the client's question directly.
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A nurse enters the room of a client and discovers the client with new right-sided weakness and slurred speech. Which of the following actions should the nurse take?
- A. Administer thrombolytics
- B. Call for help
- C. Provide the client with water to test the gag reflex
- D. Perform carotid massage
Correct Answer: B
Rationale: The correct action is to call for help (Choice B). This is because the client is displaying signs of a possible stroke, such as right-sided weakness and slurred speech. Time is critical in stroke management, and calling for help immediately can ensure the client receives prompt medical attention, such as a CT scan to confirm the diagnosis and appropriate treatment. Administering thrombolytics (Choice A) should only be done after a confirmed diagnosis to avoid potential harm. Providing water to test the gag reflex (Choice C) and performing carotid massage (Choice D) are not appropriate actions for a suspected stroke and could delay necessary interventions.
A nurse is assessing a client who reports a severe headache and stiff neck. The nurse's assessment reveals positive Kernig's and Brudzinski's signs. Which of the following actions should the nurse perform first?
- A. Decrease bright lights
- B. Implement droplet precautions
- C. Initiate IV access
- D. Administer antibiotics
Correct Answer: B
Rationale: The correct answer is B: Implement droplet precautions. This is the first action the nurse should take because positive Kernig's and Brudzinski's signs suggest the client may have meningitis, which is highly contagious through respiratory droplets. Implementing droplet precautions will help prevent the spread of the infection to others. Decreasing bright lights (A) may be helpful for the client's comfort but is not the priority. Initiating IV access (C) and administering antibiotics (D) are important interventions but should be done after implementing precautions to prevent transmission of the infection.
A nurse is working with the hospital disaster plan with the emergency operations committee. The nurse is aware that nursing is involved in which components of the disaster plan? SELECT ALL THAT APPLY
- A. Identification of resources to meet anticipated needs
- B. Participation in comprehensive annual drills
- C. Internal and external communications
- D. Performing duties outside the typical job description
- E. Development of a decontamination plan
Correct Answer: A,B,C,E
Rationale: The correct choices are A, B, C, and E. A: Nurses identify resources needed during a disaster to meet patient needs. B: Nurses participate in drills to practice response protocols. C: Nurses play a role in both internal communication within the healthcare facility and external communication with outside agencies. E: Nurses are involved in the development of decontamination plans to ensure safety. D: While nurses may perform duties outside their normal scope during a disaster, it is not a specific component of the disaster plan. Therefore, it is incorrect.
The nurse is caring for a client with multiple sclerosis. What action does the nurse implement to increase venous return, prevent stiffness, and maintain muscle strength and endurance?
- A. Encourage the client to use ice therapy to alleviate muscle stiffness
- B. Administer interferon
- C. Administer corticosteroids
- D. Encourage the client to perform gentle stretching exercises daily
Correct Answer: D
Rationale: The correct answer is D: Encourage the client to perform gentle stretching exercises daily. Stretching exercises help increase venous return by improving circulation, prevent stiffness by maintaining joint flexibility, and maintain muscle strength and endurance by promoting muscle health. Ice therapy (choice A) may temporarily alleviate stiffness but does not address venous return or muscle strength. Administering interferon (choice B) and corticosteroids (choice C) are medications used for managing symptoms but do not directly address the goals of increasing venous return or maintaining muscle strength.
A charge nurse is making a room assignment for a client who has scabies. In which of the following rooms should the nurse place the client?
- A. A negative-pressure isolation room
- B. A private room
- C. A semi-private room with a client who has pediculosis capitis
- D. A positive-pressure isolation room
Correct Answer: B
Rationale: The correct answer is B, a private room. Scabies is transmitted through direct skin-to-skin contact, so placing the client in a private room helps prevent spread to others. Choice A, a negative-pressure isolation room, is used for airborne infections. Choice C, a semi-private room with a client who has pediculosis capitis, is incorrect because scabies and head lice are different conditions with different modes of transmission. Choice D, a positive-pressure isolation room, is used to protect immunocompromised individuals from outside pathogens.