Nokea
A nurse is planning care for a client who has acute appendicitis. Which of the following actions should the nurse plan to take?
- A. Place the client's head of bed flat
- B. Apply heat to the client's abdomen
- C. Keep the client on NPO status
- D. Administer a laxative to the client.
Correct Answer: C
Rationale: The correct answer is C: Keep the client on NPO status. This is essential to prevent exacerbation of appendicitis by reducing the risk of bowel obstruction or rupture. Allowing the intestine to rest helps decrease inflammation and pain. Placing the client's head of bed flat (A) can increase intra-abdominal pressure, worsening the condition. Applying heat to the abdomen (B) can mask symptoms and potentially lead to delay in diagnosis. Administering a laxative (D) is contraindicated as it can increase the risk of perforation. In summary, maintaining NPO status is crucial for managing acute appendicitis effectively.
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A nurse is teaching a prenatal class about infection prevention at a community center. Which of the following statements by a client indicates an understanding of the teaching?
- A. I should take antibiotics when I have a virus.'
- B. I can visit my nephew who has chickenpox 5 days after the sores have crusted'
- C. I can clean my cat's litter box during my pregnancy.'
- D. I should wash my hands for 10 seconds with hot water after working in the garden.'
Correct Answer: B
Rationale: The correct answer is B: "I can visit my nephew who has chickenpox 5 days after the sores have crusted." This response indicates understanding of infection prevention because chickenpox is contagious until the sores crust over completely, which usually takes about 5-7 days. Visiting the nephew after this period reduces the risk of contracting the virus.
Incorrect options:
A: Taking antibiotics for a virus is ineffective as antibiotics only work against bacterial infections, not viruses.
C: Cleaning a cat's litter box can expose pregnant individuals to toxoplasmosis, a parasitic infection harmful to the fetus.
D: Washing hands for only 10 seconds with hot water is insufficient to effectively remove germs. The CDC recommends washing for at least 20 seconds with soap and water.
A nurse is assessing a client who has histrionic personality disorder. Which of the following manifestations should the nurse expect?
- A. Suspicious of others
- B. Callousness
- C. Self-centered behavior
- D. Violates other's rights
Correct Answer: C
Rationale: The correct answer is C: Self-centered behavior. Individuals with histrionic personality disorder typically exhibit attention-seeking, dramatic, and overly emotional behaviors. They often crave approval and validation from others, focusing on themselves and their own needs. This behavior aligns with the core characteristics of histrionic personality disorder.
Choice A (Suspicious of others) is incorrect as suspicion is not a defining trait of histrionic personality disorder. Choice B (Callousness) is inconsistent as histrionic individuals tend to be overly emotional rather than callous. Choice D (Violates other's rights) is not a common feature of histrionic personality disorder.
In summary, the nurse should expect self-centered behavior in a client with histrionic personality disorder, as they typically display attention-seeking and dramatic behaviors, seeking validation and approval from others.
A nurse is caring for a client who is receiving brachytherapy for endometrial cancer. Which of the following actions should the nurse take?
- A. Discard the radioactive source in the client's trash can.
- B. Place the client's soiled bed linens in a biohazard bag outside the client's room
- C. Wear an isolation gown when caring for the client
- D. Keep visitors at least 6 feet (1.8 m) away from the client.
Correct Answer: D
Rationale: The correct answer is D: Keep visitors at least 6 feet (1.8 m) away from the client. This is important in brachytherapy as the client is emitting radiation. By keeping visitors at a safe distance, the nurse ensures their safety from radiation exposure. A: Discarding the radioactive source in the trash can is incorrect as it poses a risk to others. B: Placing soiled linens in a biohazard bag is not directly related to radiation safety. C: Wearing an isolation gown does not provide sufficient protection against radiation. Therefore, it is important for the nurse to maintain distance to prevent radiation exposure to visitors.
A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications?
- A. Acetylcysteine
- B. Protamine
- C. Naloxone
- D. Flumazenil
Correct Answer: C
Rationale: The correct answer is C: Naloxone. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, such as respiratory depression. In this case, the client's respiratory rate of 10/min indicates opioid overdose due to hydromorphone. Naloxone administration can help reverse the respiratory depression and restore normal breathing.
Choice A: Acetylcysteine is used for acetaminophen overdose, not opioid overdose.
Choice B: Protamine is used to reverse the effects of heparin, not opioids.
Choice D: Flumazenil is a benzodiazepine antagonist, not an opioid antagonist.
Therefore, the most appropriate choice in this scenario is Naloxone to address the opioid overdose and respiratory depression.
A nurse is speaking with the caregiver of a client who has Alzheimer's disease. The caregiver states, 'Providing constant care is very stressful and is affecting all areas of my life.' Which of the following actions should the nurse take?
- A. Suggest that the caregiver seek a prescription for an antipsychotic medication for the client.
- B. Recommend allowing the client to have time alone in their room throughout the day
- C. Discuss methods of how to communicate with the client about resolving problem behaviors
- D. Assist the caregiver to arrange for a daycare program for the client
Correct Answer: D
Rationale: The correct answer is D: Assist the caregiver to arrange for a daycare program for the client. This option addresses the caregiver's concern of stress and the impact on their life by providing respite care. This allows the caregiver to have a break and attend to their own needs while ensuring the client's safety and well-being. It promotes caregiver self-care and prevents burnout.
Option A is incorrect as prescribing antipsychotic medication is not appropriate for caregiver stress. Option B may not address the caregiver's need for a break or support. Option C, while important, focuses on communication strategies rather than providing immediate relief for the caregiver.