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A nurse is caring for a client with schizophrenia. Which of the following assessment findings should the nurse expect?
- A. Decreased level of consciousness
- B. Inability to identify common objects
- C. Poor problem-solving ability
- D. Preoccupation with somatic disturbances
Correct Answer: B
Rationale: In schizophrenia, clients often display an inability to identify common objects due to cognitive impairment. This is known as associative agnosia, where individuals struggle to recognize familiar objects, faces, or sounds. Choices A, C, and D are not typically associated with schizophrenia. Decreased level of consciousness is more indicative of conditions like head trauma or drug overdose. Poor problem-solving ability may be seen in various mental health disorders but is not specific to schizophrenia. Preoccupation with somatic disturbances is more commonly seen in somatic symptom disorders or somatic delusions, not a typical finding in schizophrenia.
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How should pain be assessed in a non-verbal patient?
- A. Observe facial expressions
- B. Use the Wong-Baker faces scale
- C. Assess heart rate
- D. Ask the patient to rate their pain
Correct Answer: A
Rationale: Observing facial expressions is essential in assessing pain levels in non-verbal patients. Non-verbal cues, such as facial grimacing, furrowed brows, or clenched jaws, can provide valuable information about the patient's pain experience. Using the Wong-Baker faces scale or assessing heart rate may not be as effective in non-verbal patients as they are unable to communicate their pain through these methods. Asking the patient to rate their pain is also not suitable for non-verbal patients as they may not have the ability to verbally communicate their pain levels.
A nurse is planning care for a client who has a stage 3 pressure injury. Which of the following interventions should the nurse include in the plan of care?
- A. Cleanse the wound with povidone-iodine solution daily.
- B. Irrigate the wound with hydrogen peroxide.
- C. Reposition the client every 4 hours.
- D. Use a moisture barrier ointment.
Correct Answer: D
Rationale: The correct answer is to use a moisture barrier ointment. This intervention helps protect the skin and promote healing in clients with stage 3 pressure injuries. Cleansing the wound with povidone-iodine solution daily (Choice A) can be too harsh and may delay healing by damaging the surrounding skin. Irrigating the wound with hydrogen peroxide (Choice B) is not recommended as it can be cytotoxic to healing tissue. While repositioning the client every 4 hours (Choice C) is an essential intervention in preventing pressure injuries, it is not directly related to the care of an existing stage 3 pressure injury.
A client is receiving discharge teaching regarding a new prescription for warfarin. Which of the following statements by the client indicates a need for further teaching?
- A. I will eat more leafy green vegetables while taking warfarin.
- B. I will have my INR checked regularly while taking warfarin.
- C. I will avoid drinking grapefruit juice while taking warfarin.
- D. I will use a soft toothbrush while taking warfarin.
Correct Answer: A
Rationale: The correct answer is A. Clients taking warfarin should avoid leafy green vegetables as they are high in vitamin K, which can reduce the effectiveness of the medication. Therefore, the statement 'I will eat more leafy green vegetables while taking warfarin' indicates a need for further teaching. Choice B is correct as regular monitoring of INR levels is necessary for clients on warfarin. Choice C is correct as grapefruit juice can interact with warfarin and should be avoided. Choice D is correct as using a soft toothbrush is recommended to prevent gum bleeding while on warfarin.
A nurse is planning care for a client who has a new prescription for a peripheral intravenous (IV) catheter. Which of the following actions should the nurse take to prevent infection?
- A. Shave the hair at the insertion site.
- B. Cleanse the site with povidone-iodine.
- C. Wear sterile gloves when changing the dressing.
- D. Change the IV site every 48 to 72 hours.
Correct Answer: D
Rationale: The correct action to prevent infection when caring for a client with a new peripheral IV catheter is to change the IV site every 48 to 72 hours. Shaving the hair at the insertion site can actually increase the risk of infection by causing microabrasions in the skin. While cleansing the site with povidone-iodine is important before insertion, it is not necessary to continue doing so once the IV is in place. Wearing sterile gloves when changing the dressing is crucial for maintaining aseptic technique but does not directly prevent infection related to the IV site itself.
What is the most appropriate intervention for a patient with confusion post-surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Administer IV fluids
- D. Perform a neurological assessment
Correct Answer: A
Rationale: Administering oxygen is the most appropriate intervention for a patient with confusion post-surgery because it helps alleviate confusion caused by potential hypoxia. In a post-surgical setting, confusion can be a sign of decreased oxygen levels in the blood due to various reasons such as respiratory depression, decreased lung function, or other complications. Administering oxygen can quickly address hypoxia, improving oxygenation to the brain and reducing confusion. Repositioning the patient, administering IV fluids, or performing a neurological assessment are not the primary interventions for confusion related to hypoxia post-surgery.