Nokea
A patient is admitted to the ER and presents as very talkative, highly alert, pupil dilated, has a relatively high temperature and is sweating. He or she tells you he or she never needs to sleep anymore. What would you suspect is causing the patient's condition?
- A. The patient is under the influence of heroin.
- B. The patient is under the influence of amphetamines.
- C. The patient is under the influence of oxycodone.
- D. The patient is under the influence of Oxycodan.
Correct Answer: B
Rationale: Symptoms such as talkativeness, alertness, dilated pupils, and hyperthermia are characteristic of amphetamine use.
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What behavioral clues will you watch for to identify an increased risk for suicide?
- A. Deep breathing exercises
- B. Avoid social interactions
- C. Ignore stressors
- D. Increase workload
Correct Answer: D
Rationale: The correct answer is D because it is the most appropriate response based on physiological and medical principles.
A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the client's blood pressure is much higher than previous readings & the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome?
- A. Determining if the UAP knew how to take blood pressure
- B. Double-checking the UAP by taking another blood pressure
- C. Providing more appropriate supervision of the UAP
- D. Taking the blood pressure instead of delegating the task
Correct Answer: C
Rationale: The correct answer is C: Providing more appropriate supervision of the UAP. By providing adequate supervision, the nurse can ensure that the UAP is performing tasks correctly and can intervene if any issues arise. This would have likely prevented the negative outcome as the nurse could have identified the high blood pressure and changed mental status earlier.
A: Determining if the UAP knew how to take blood pressure - While assessing the UAP's competence is important, it does not address the need for ongoing supervision and oversight.
B: Double-checking the UAP by taking another blood pressure - This approach does not address the root cause of the issue, which is the lack of appropriate supervision.
D: Taking the blood pressure instead of delegating the task - This is not a sustainable solution as delegating tasks to UAPs is a common practice in healthcare settings. Providing appropriate supervision is key to ensuring safe and effective delegation.
When assessing a skin lesion, you look for A-asymmetry, B-irregular borders, C-variegated colors, D-diameter, and E-
- A. Edema.
- B. Erythema.
- C. Elevation.
- D. Ever-changing.
Correct Answer: C
Rationale: Elevation is one of the ABCDE criteria for assessing suspicious skin lesions.
Which physiological response is often associated with surgery-related stress?
- A. Bronchial constriction.
- B. Decreased cortisol levels.
- C. Peripheral vasodilation.
- D. Sodium and water retention.
Correct Answer: D
Rationale: Stress activates the renin-angiotensin-aldosterone system, leading to sodium and water retention.
A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What action should the nurse anticipate?
- A. Decrease the heparin rate.
- B. Increase the heparin rate.
- C. No change to the heparin rate.
- D. Stop the heparin; start warfarin (Coumadin).
Correct Answer: B
Rationale: The correct answer is B: Increase the heparin rate. A PTT of 25 seconds indicates that the client's blood is not adequately anticoagulated, as the therapeutic range for PTT is typically around 60-80 seconds for heparin therapy. Therefore, the nurse should anticipate increasing the heparin rate to achieve the desired anticoagulant effect and prevent further clot formation.
Incorrect choices:
A: Decreasing the heparin rate would further decrease the anticoagulant effect, potentially putting the client at risk for thrombus progression.
C: No change to the heparin rate would not address the subtherapeutic PTT level and could lead to inadequate anticoagulation.
D: Stopping heparin and starting warfarin is not appropriate at this time as warfarin takes time to reach therapeutic levels, whereas heparin provides immediate anticoagulation for acute situations like a pulmonary embolism.