Nokea
A patient in heroin withdrawal comes to the nurse's station demanding a narcotic saying he or she is going to die from the withdrawal. The patient received detox medication 30 minutes ago. What is the best response?
- A. Call a rapid response before the patient has a seizure.
- B. Tell the patient he or she is not going to die from opioid withdrawal and that you will see if he or she has any PRN medications available.
- C. Tell the patient to speak with the practitioner in the morning.
- D. Tell the patient that you will call the practitioner now to see if the practitioner will order a narcotic.
Correct Answer: B
Rationale: Reassurance and checking for available PRN medications address both the patient's anxiety and potential need for additional symptom management.
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Which standardized nursing terminologies specifically relate to the steps of the nursing process (select all that apply)?
- A. Omaha System
- B. Nursing Outcomes Classification (NOC)
- C. Nursing Interventions Classification (NIC)
- D. NANDA International: Nursing Diagnoses
Correct Answer: B
Rationale: NOC, NIC, and NANDA International directly correspond to the steps of the nursing process: outcomes, interventions, and diagnoses.
What stressors is she experiencing (select all that apply)?
- A. Change in role within the family
- B. Lack of respite from caregiving responsibilities
- C. Conflict in the family related to decisions about caregiving
- D. Financial depletion of resources as a result of her inability to work
Correct Answer: C
Rationale: The correct answers are all listed. Each option represents a potential stressor experienced by the caregiver due to her father's condition and the dynamics within her family.
Which risk is more prone to clients who administer carbamazepine for bipolar disorder?
- A. Risk for injury
- B. Risk for self-directed violence
- C. Risk for imbalanced nutrition
- D. Risk for infection
Correct Answer: D
Rationale: Carbamazepine can suppress the immune system, increasing the risk of infections.
A client who will undergo a bronchoscopy procedure with a rigid scope and general anesthesia will have their neck in which of the following positions?
- A. A flexed position
- B. An extended position
- C. A neutral position
- D. A hyperextended position
Correct Answer: D
Rationale: The correct answer is D: A hyperextended position. During bronchoscopy with a rigid scope, the client's neck needs to be hyperextended to facilitate optimal insertion of the scope into the trachea. Hyperextension straightens and opens up the airway, providing better visualization and access to the bronchial tree.
Choice A (flexed position) would obstruct the airway and make insertion difficult. Choice B (extended position) would not provide the necessary alignment for scope insertion. Choice C (neutral position) may not offer sufficient airway visibility and access.
In summary, a hyperextended position is crucial for successful bronchoscopy with a rigid scope, as it ensures proper alignment, airway visibility, and scope insertion.
Priority Decision: While the nurse is obtaining a health history the patient tells the nurse, "I am so tired I can hardly function." What is the nurse’s best action at this time?
- A. Stop the interview and leave the patient alone to be able to rest.
- B. Arrange another time with the patient to complete the interview.
- C. Question the patient further about the characteristics of the symptoms.
- D. Reassure the patient that the symptoms will improve when treatment has had time to be effective.
Correct Answer: C
Rationale: The correct answer is 'Question the patient further about the characteristics of the symptoms.' Fatigue could indicate underlying health issues such as anemia, infection, or chronic illness. Further questioning helps identify potential causes and prioritize care.