Nokea
A nurse is providing an in service about client evacuation during a fire. Which of the following clients should the nurse instruct the staff to evacuate first?
- A. A client who uses a wheelchair and is confused
- B. A client who is bedridden and wears a hearing aid
- C. A client who is ambulatory and receiving oxygen
- D. A client who has a fracture and is in balance suspension traction
Correct Answer: A
Rationale: The correct answer is A because a client who uses a wheelchair and is confused is at the highest risk during a fire evacuation due to mobility limitations and decreased ability to follow instructions. Evacuating this client first ensures their safety and prevents potential delays in the evacuation process.
Choice B is incorrect because a bedridden client wearing a hearing aid can still be safely evacuated with assistance. Choice C is incorrect as an ambulatory client receiving oxygen can usually move independently and should be evacuated after the client in a wheelchair. Choice D is incorrect because a client with a fracture in traction can be safely moved with proper equipment and should not be the first priority for evacuation.
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For each assessment finding, click to specify if the finding is consistent with psychosis or mania. Each finding may support more than one diagnosis.
- A. Hallucinations
- B. Lack of sleep
- C. Excessive spending habits
- D. Disorganized thought process
- E. Pressured speech
Correct Answer: A: Psychosis; B, C, D, E: Mania
Rationale: The correct answer is A: Psychosis; B, C, D, E: Mania. Hallucinations are typically associated with psychosis due to perceptual disturbances. Lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are all characteristic features of mania, which is a key symptom of Bipolar Disorder. Mania involves elevated mood, increased energy levels, impulsivity, and risky behavior, such as excessive spending. Disorganized thought process and pressured speech are manifestations of the racing thoughts and flight of ideas seen in mania. In summary, while hallucinations are consistent with psychosis, the other findings (lack of sleep, excessive spending habits, disorganized thought process, pressured speech) are more indicative of mania due to the presence of manic symptoms.
A nurse is planning care for a client who sustained a major burn over 20% of the body. Which of the following interventions should the nurse include to support the client's nutritional requirements?
- A. Maintain calorie intake at 1,500 per day
- B. Provide a low-protein, high-carbohydrate diet.
- C. Keep a calorie count for foods and beverages.
- D. Schedule meals at 6-hr intervals
Correct Answer: C
Rationale: The correct answer is C: Keep a calorie count for foods and beverages. For a client with major burn injuries, accurate monitoring of calorie intake is crucial to support nutritional requirements for wound healing and metabolic demands. This intervention allows the nurse to adjust the diet as needed to meet the client's energy needs. Choice A is incorrect as calorie intake requirements may vary based on individual needs. Choice B is incorrect as a high-protein diet is essential for wound healing in burn patients. Choice D is incorrect as frequent, smaller meals are typically recommended for burn patients to support healing and prevent muscle breakdown.
A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following hip replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Place a throw rug over electrical cords
- C. Mark the edges of the doorway to the house with tape.
- D. Ensure that area rugs have rubber backs.
Correct Answer: D
Rationale: The correct answer is D: Ensure that area rugs have rubber backs. This instruction helps prevent slipping and falling, which is crucial for a postoperative hip replacement patient. Rubber-backed rugs provide stability and reduce the risk of accidents. Option A is incorrect as wearing shoes at home can increase the risk of falls. Option B is incorrect as placing a throw rug over electrical cords can lead to tripping hazards. Option C is incorrect as marking doorways with tape does not address home safety concerns for a postoperative patient.
A nurse is caring for a client who has severe hypertension and is to receive nitroprusside via continuous IV infusion. Which of the following actions should the nurse plan to take?
- A. Monitor blood pressure every 2 hr.
- B. Attach an inline filter to the IV tubing
- C. Protect the IV bag from exposure to light.
- D. Keep calcium gluconate at the client's bedside.
Correct Answer: C
Rationale: The correct answer is C: Protect the IV bag from exposure to light. Nitroprusside is light-sensitive and can degrade when exposed to light, leading to the formation of toxic metabolites. By protecting the IV bag from light exposure, the nurse ensures the medication's stability and prevents potential harm to the client. Monitoring blood pressure every 2 hours (Choice A) is a standard practice for clients receiving nitroprusside but is not the most critical action. Attaching an inline filter to the IV tubing (Choice B) is important to prevent particulate matter from entering the client's bloodstream but is not specific to nitroprusside administration. Keeping calcium gluconate at the client's bedside (Choice D) is unrelated to nitroprusside administration and is not necessary for this situation.
A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions?
- A. Shrugs his shoulders
- B. Sticks his tongue out
- C. Frowns symmetrically
- D. Identifies a sour taste
Correct Answer: A
Rationale: The correct answer is A: Shrugs his shoulders. Cranial nerve XI, also known as the spinal accessory nerve, is responsible for controlling the trapezius and sternocleidomastoid muscles, which are involved in shoulder shrugging. When the nurse asks the client to shrug his shoulders against resistance, she is testing the integrity of cranial nerve XI. This action allows the nurse to assess the strength and function of this particular cranial nerve.
Choices B, C, and D are incorrect because they test other cranial nerves. Sticking the tongue out (B) tests cranial nerve XII (hypoglossal nerve), frowning symmetrically (C) tests cranial nerve VII (facial nerve), and identifying a sour taste (D) tests cranial nerve IX (glossopharyngeal nerve). These actions do not involve cranial nerve XI and are therefore not indicators of its intactness.