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A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
- A. DIC is characterized by an elevated platelet count.
- B. DIC is caused by abnormal coagulation involving fibrinogen.
- C. DIC is controllable with lifelong heparin usage.
- D. DIC is a genetic disorder involving a vitamin K deficiency.
Correct Answer: B
Rationale: Correct Answer: B - DIC is caused by abnormal coagulation involving fibrinogen.
Rationale: DIC is a complex disorder characterized by widespread activation of coagulation leading to both excessive clot formation and consumption of clotting factors, including fibrinogen. This results in abnormal coagulation and fibrinolysis, leading to both bleeding and clotting throughout the body. Elevated platelet count is not a feature of DIC; instead, platelets are consumed in the process. Lifelong heparin usage is not a standard treatment for DIC, as it is a condition that requires specific management based on the underlying cause. DIC is not a genetic disorder but rather an acquired condition often triggered by severe infections, sepsis, trauma, or other critical illnesses. Vitamin K deficiency is associated with certain clotting factor deficiencies but is not the primary cause of DIC.
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A nurse is caring for a client who is experiencing a manic episode. Other clients begin to complain about her disruptive behavior on the unit. Which of the following actions should the nurse take?
- A. Warn the client that further disruptions will result in seclusion.
- B. Ask the client to recommend consequences for her disruptive behavior.
- C. Set limits on the client's behavior and be consistent in approach.
- D. Ignore the client's behavior,realizing it is consistent with her illness.
Correct Answer: C
Rationale: The correct answer is C: Set limits on the client's behavior and be consistent in approach. This is the best course of action because it maintains a therapeutic environment while ensuring the safety and well-being of all clients. By setting limits, the nurse establishes boundaries for acceptable behavior during the manic episode, helping to prevent harm and maintain order on the unit. Consistency in approach is crucial to provide the client with structure and predictability, which can help manage the manic symptoms and reduce potential disruptions.
Choice A is not the best option as it may escalate the situation and does not address the underlying issue. Choice B is not appropriate as it puts the responsibility on the client to determine consequences, which may not be effective in managing the behavior. Choice D is incorrect as ignoring the behavior can compromise the safety of other clients and is not a therapeutic approach to managing manic episodes.
The physician orders a Lidocaine drip to infuse at 2 mg/min. The drug is available as 2 gm in 500 mL of fluid. Solve for mL/hr.
Correct Answer: 3
Rationale: To solve for mL/hr, we first need to convert 2 gm to mg (2000 mg) and calculate the total volume in mL (500 mL). Then, we divide the total volume by the rate of infusion (2 mg/min) to get mL/min (250 mL/min). Finally, multiply this by 60 to get mL/hr (15000 mL/hr). Choice 3 is correct because it correctly follows these steps. Other choices are incorrect due to miscalculations or skipping a step.
A nurse is assessing a client who is experiencing a thyroid storm. Which of the following findings should the nurse anticipate?
- A. Coma
- B. Hypothermia
- C. Tachycardia
- D. Fruity smelling breath
Correct Answer: C
Rationale: The correct answer is C: Tachycardia. In a thyroid storm, there is an excessive release of thyroid hormones leading to severe symptoms. Tachycardia is a hallmark sign due to the increased metabolic rate and sympathetic response. Coma (A) is a severe complication but not an anticipated finding. Hypothermia (B) is incorrect as the body temperature is typically elevated. Fruity smelling breath (D) is more indicative of diabetic ketoacidosis, not thyroid storm.
A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include in the plan?
- A. Hyperextend the client's neck.
- B. Instruct the client to deep breathe every 4 hr.
- C. Place the head of the client's bed in the flat position.
- D. Check the client's voice every 2 hr.
Correct Answer: B,D
Rationale: The correct answers are B and D. Instructing the client to deep breathe every 4 hours helps prevent respiratory complications post-thyroidectomy. Checking the client's voice every 2 hours is important to monitor for vocal cord damage, a potential complication. Choice A is incorrect as hyperextending the client's neck can put strain on the surgical site. Choice C is incorrect as the head of the bed should be elevated to reduce swelling and promote drainage.
A nurse is planning care for a client who has dependent personality disorder. Which of the following actions should the nurse plan to take?
- A. Monitor the client closely to prevent self-mutilation.
- B. Set limits to prevent exploitation of other clients.
- C. Give positive feedback when the client is assertive with staff or clients.
- D. Discourage flamboyant or seductive behaviors.
Correct Answer: C
Rationale: The correct answer is C: Give positive feedback when the client is assertive with staff or clients. This is because individuals with dependent personality disorder often struggle with low self-esteem and lack of confidence in their own abilities. By providing positive feedback when the client demonstrates assertiveness, the nurse can reinforce and encourage this behavior, ultimately promoting the client's independence and self-confidence.
Choice A is incorrect because monitoring for self-mutilation is more relevant for clients with other mental health disorders such as borderline personality disorder. Choice B is incorrect as setting limits to prevent exploitation is more appropriate for clients with antisocial personality disorder. Choice D is incorrect as discouraging flamboyant or seductive behaviors is more relevant for clients with histrionic personality disorder.