Nokea
A nurse is caring for a client who requires seclusion to prevent harm to others on the unit. Which of the following is an appropriate action for the nurse to take?
- A. Document the client's behavior prior to being placed in seclusion,
- B. Assess the client's behavior once every hour
- C. Offer fluids every 2 hr.
- D. Discuss with the client his inappropriate behavior prior to seclusion
Correct Answer: A
Rationale: The correct answer is A: Document the client's behavior prior to being placed in seclusion. This is important for legal and clinical reasons as it provides a clear record of the client's behavior leading up to seclusion, ensuring transparency and accountability. Assessing behavior once every hour (choice B) may not be sufficient for monitoring the client's condition in seclusion. Offering fluids every 2 hours (choice C) is important for hydration but not directly related to seclusion. Discussing inappropriate behavior with the client (choice D) may escalate the situation and is not recommended in this scenario.
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The client is at risk for developing-----due to---
- A. mania
- B. serotonin syndrome
- C. psychosis
- D. feelings of hopelessness
- E. adverse effects of paroxetine
- F. anxiety
Correct Answer: B,E
Rationale: Increasing paroxetine while discontinuing fluoxetine can lead to serotonin syndrome.
Which of the following actions should the nurse take?
- A. Infuse the medication over 10 min
- B. Instruct the client to notify the provider if diarrhea develops
- C. Refrigerate the medication after reconstitution.
- D. Check the client for a sulfa allergy.
Correct Answer: B
Rationale: The correct answer is B: Instruct the client to notify the provider if diarrhea develops. This action is important because diarrhea can be a potential side effect of medication, especially antibiotics, and may indicate a serious adverse reaction. It is crucial for the client to inform the provider promptly to prevent complications.
Choice A is incorrect as it refers to a specific administration instruction for a medication, not related to client monitoring. Choice C is incorrect as it pertains to storage of medication, not client education. Choice D is incorrect as it focuses on assessing for a specific allergy, not related to ongoing client monitoring.
A nurse is caring for a client who asks for information regarding organ donation. Which of the following responses should the nurse make?
- A. I cannot be a witness for your consent to donate.
- B. You must be at least 21, years of age to become an organ donorâ€
- C. Your desire to be an organ donor must be documented in writingâ€
- D. Your name cannot be removed once you are listed on the organ donor list.
Correct Answer: C
Rationale: The correct response should be C: "Your desire to be an organ donor must be documented in writing." This is the correct answer because in order for someone to become an organ donor, their decision must be documented in writing, typically through an organ donor card, a driver's license designation, or registration with a national organ donation registry. This documentation is crucial to ensure that the individual's wishes are respected and followed in the event of their death.
The other choices are incorrect:
A: "I cannot be a witness for your consent to donate." This statement is incorrect as a nurse can provide information and support regarding organ donation, but they are not required to be a witness for consent.
B: "You must be at least 21 years of age to become an organ donor." This statement is incorrect as the legal age requirement to become an organ donor varies by country or state, and it is not always 21 years of age.
D: "Your name cannot be removed once you are listed
Which of the following actions is the priority for the nurse to take?
- A. Evaluate the client for orthostatic hypotension.
- B. Monitor the client's urine output.
- C. Obtain the client's laboratory results.
- D. Check the client for nasal congestion
Correct Answer: A
Rationale: Orthostatic hypotension is a potential adverse effect of valsartan overdose.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Instruct the client to avoid live vaccines, Instruct the client to use mild soaps for cleansing skin, Instruct the client to avoid foods high in purities, Instruct the client to apply tropical analgesics, Instruct the client to apply heat
- B. Systemic lupus erythematous, Osteoarithritis, Gout, Rheumatoid arthritis(RA)
- C. Uric acid level, ESH, Joint deformities, lymphadenopathy, ANA
Correct Answer:
Rationale: Gout presents with elevated uric acid levels.