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A nurse is caring for a client with a scheduled procedure. While preparing the client for transport they appear anxious and ask the nurse where they should hide their cellphone during the procedure. The nurse offers to lock the item in a secure area. Which category of Maslow's hierarchy of needs is the nurse addressing?
- A. Safety needs
- B. Esteem needs
- C. Love and belonging needs
- D. Physiological needs
Correct Answer: A
Rationale: The correct answer is A: Safety needs. At this moment, the nurse is addressing the client's need for safety by offering to secure their cellphone. Safety needs in Maslow's hierarchy refer to feeling secure, stable, and protected. By ensuring the client's belongings are safe, the nurse is addressing this fundamental need, which is crucial for the client's well-being during the procedure. Other choices are incorrect because: B: Esteem needs focus on self-respect and recognition from others, C: Love and belonging needs refer to relationships and social connections, and D: Physiological needs pertain to basic requirements like food and water, none of which are directly addressed in this scenario.
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A nurse in an emergency department is performing triage on a group of clients. Which of the following clients should the nurse see first?
- A. A client who has heart failure and peripheral edema
- B. A client who reports urinary burning and a temperature of 29.2° C (102.51 F)
- C. A client who has cirrhosis of the liver and bruising on their arms
- D. A client who has a new onset of atrial fibrillation and a heart rate of 152/min
Correct Answer: D
Rationale: The correct answer is D because a new onset of atrial fibrillation with a heart rate of 152/min indicates a potentially life-threatening cardiac condition requiring immediate attention to prevent complications such as stroke or heart failure. Atrial fibrillation can lead to decreased cardiac output and increase the risk of blood clots forming in the heart. The high heart rate can also lead to hemodynamic instability. A prompt assessment and intervention are crucial to stabilize the client's condition.
Choice A is incorrect as heart failure with peripheral edema, while concerning, does not pose an immediate life-threatening risk compared to a new onset of atrial fibrillation.
Choice B is incorrect as urinary burning and a temperature of 29.2° C (102.51 F) may indicate a urinary tract infection, which is important but not as urgent as the cardiac issue in choice D.
Choice C is incorrect as bruising in a client with cirrhosis of the liver is concerning for potential bleeding disorders, but it is not
A nurse is teaching a class about sleep disorders. The nurse should include that which of the following conditions can cause obstructive sleep apnea (OSA)?
- A. Heart failure
- B. Brainstem injury
- C. Recent weight loss
- D. Enlarged tonsils
Correct Answer: D
Rationale: The correct answer is D: Enlarged tonsils. Enlarged tonsils can physically obstruct the airway during sleep, leading to obstructive sleep apnea (OSA). This obstruction causes pauses in breathing during sleep, resulting in disrupted sleep patterns and decreased oxygen levels in the blood. Heart failure (A) is incorrect because it is not a direct cause of OSA. Brainstem injury (B) may disrupt the sleep-wake cycle but is not a common cause of OSA. Recent weight loss (C) can actually improve OSA symptoms by reducing the amount of tissue in the airway. Therefore, the most likely condition to cause OSA among the choices given is enlarged tonsils.
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Increased blood pressure
- B. Increased hematocrit
- C. Increased respiratory rate
- D. Increased heart rate
- E. Increased temperature
Correct Answer: A,C,D
Rationale: The correct answer is A, C, and D. Fluid overload leads to increased blood pressure due to the increased volume of fluid in the vascular system. Increased respiratory rate occurs as the body tries to compensate for the excess fluid by increasing oxygen intake. Increased heart rate is a response to the increased workload on the heart to pump the excess fluid. Increased hematocrit and temperature are not typically associated with fluid overload. Hematocrit may actually be decreased due to hemodilution, and temperature is usually unaffected unless there is an underlying infection.
The nurse is caring for a client who has had partial removal of the parathyroid gland. The client reports numbness and tingling of the hands and fingers. Which lab value would the nurse expect to see?
- A. Chloride 112
- B. Calcium 7.5
- C. Potassium 4.0
- D. Calcium 12.1
Correct Answer: B
Rationale: The correct answer is B: Calcium 7.5. With partial removal of the parathyroid gland, there may be decreased production of parathyroid hormone leading to hypocalcemia. Numbness and tingling in the hands and fingers are classic symptoms of hypocalcemia. A low calcium level of 7.5 is indicative of this condition.
Choice A: Chloride 112 is not related to symptoms of numbness and tingling.
Choice C: Potassium 4.0 is within the normal range and not associated with symptoms of hypocalcemia.
Choice D: Calcium 12.1 indicates hypercalcemia, not hypocalcemia, which would not cause numbness and tingling.
A nurse is caring for a client whose partner has recently died. The client states, 'I am learning how to pay my own bills.' The nurse should identify that the client is experiencing which of the following tasks in Worden’s Four Tasks of Grieving?
- A. Experiencing the pain of grief
- B. Finding an enduring connection while embarking on a new life
- C. Accepting the reality of the loss
- D. Adjusting to an environment without the deceased
Correct Answer: D
Rationale: The correct answer is D: Adjusting to an environment without the deceased. This task involves adapting to life without the presence of the deceased partner, such as taking on new responsibilities like paying bills. It signifies a significant step in the grieving process, as the individual begins to establish a new routine and sense of normalcy without their loved one.
Choice A (Experiencing the pain of grief) is not the correct answer because this task refers to acknowledging and processing the emotional pain associated with the loss, which is a different aspect of grieving.
Choice B (Finding an enduring connection while embarking on a new life) is not the correct answer as it involves integrating the memory and influence of the deceased into the individual's ongoing life, which is different from adjusting to the practical aspects of life without them.
Choice C (Accepting the reality of the loss) is not the correct answer as it pertains to coming to terms with the fact that the loved one has passed away, which is an important