Nokea
A postpartum client reports severe headache, visual disturbances, and epigastric pain. Which nursing action is most appropriate?
- A. Encouraging the client to rest in a dark, quiet room
- B. Providing acetaminophen for headache relief
- C. Assessing blood pressure and other vital signs
- D. Offering a massage to relieve muscle tension
Correct Answer: C
Rationale: The most appropriate nursing action in this situation is to assess the client's blood pressure and other vital signs. The client's symptoms of severe headache, visual disturbances, and epigastric pain could be indicative of preeclampsia or eclampsia, which are serious conditions that require immediate medical attention. Checking the blood pressure and other vital signs will help determine if the client's symptoms are related to abnormal blood pressure levels, which is critical in identifying and managing hypertensive disorders in postpartum clients. Once the assessment is completed, appropriate medical interventions can be initiated promptly if necessary.
You may also like to solve these questions
Which of the following is NOT included among the factors that should be considered by the nurse or the pregnant woman in interpreting results of pregnancy test?
- A. Last menstrual period
- B. Type of pregnancy test
- C. Previous pregnancy
- D. Menstrual cycle length
Correct Answer: B
Rationale: The type of pregnancy test is not a factor that should be considered by the nurse or the pregnant woman in interpreting the results of a pregnancy test. Factors such as the last menstrual period, previous pregnancy history, and menstrual cycle length play a crucial role in determining the reliability and accuracy of the pregnancy test results.
Signs such as using tissues to doorknobs develop because the patient is ________.
- A. unconsciously controlling unacceptable impulses or feelings
- B. Listening to voices that tell her that doorknobs are unclean
- C. consciously using this method of punishing herself
- D. fulfilling a need to punish others procedure by carrying out annoying
Correct Answer: A
Rationale: Signs such as using tissues to doorknobs suggest that the patient is unconsciously controlling unacceptable impulses or feelings. This behavior falls under the category of defense mechanisms, specifically displacement, where the individual redirects their emotions from a threatening target to a safer one. In this case, the patient may be experiencing anxiety or fear related to contamination or germs, leading them to use tissues to avoid touching doorknobs directly. It is a way for the patient to manage their underlying emotions, albeit unconsciously, through this compulsive behavior.
During CPR, which of the following actions should be performed immediately after activating the emergency response system?
- A. Start chest compressions.
- B. Check for breathing.
- C. Perform abdominal thrusts.
- D. Assess pulse.
Correct Answer: A
Rationale: After activating the emergency response system, the immediate priority in CPR is to begin chest compressions to support blood circulation. High-quality chest compressions are crucial in providing oxygen to vital organs, especially the brain, during cardiac arrest. Starting chest compressions promptly can improve the chances of survival for the person in need of CPR. Checking for breathing, performing abdominal thrusts, or assessing pulse should only be done after initiating chest compressions in the CPR sequence.
It a medicine is unavailable and therefore not given to the patient, how is it charted?
- A. Leave it blank.
- B. Sign and make an explanation in the Nurses Notes.
- C. With an asterisk or mark, as per hospital protocol.
- D. Write the letter.
Correct Answer: B
Rationale: When a medication is unavailable and therefore not given to the patient, it is important to document this in the Nurses Notes along with an explanation. Leaving it blank (Option A) may lead to confusion or errors as the reason for not administering the medication would not be clear. Using an asterisk or mark as per hospital protocol (Option C) may not provide enough information about why the medication was missed. Writing the letter (Option D) without any explanation would not suffice in terms of documentation and accountability. Therefore, signing and making an explanation in the Nurses Notes (Option B) is the correct way to chart when a medication is unavailable. This ensures proper documentation of the situation and helps in maintaining the continuity of care for the patient.
A patient with advanced dementia is bedbound and at risk of developing pressure ulcers. What intervention should the palliative nurse prioritize to prevent pressure ulcer formation?
- A. Turn the patient every 2 hours to relieve pressure on bony prominences.
- B. Apply barrier creams or moisture barriers to protect vulnerable skin areas.
- C. Use pressure-relieving support surfaces, such as specialized mattresses or cushions.
- D. Administer prophylactic antibiotics to prevent infection in at-risk skin areas.
Correct Answer: C
Rationale: The most effective intervention to prevent pressure ulcers in bedbound patients at risk, such as those with advanced dementia, is to use pressure-relieving support surfaces like specialized mattresses or cushions. These surfaces help distribute the pressure evenly, reducing the risk of pressure ulcer formation on bony prominences. Turning the patient every 2 hours (choice A) can also help relieve pressure, but it may not be sufficient to prevent pressure ulcers in high-risk individuals. Applying barrier creams or moisture barriers (choice B) can help protect the skin but may not address the underlying issue of pressure on vulnerable areas. Administering prophylactic antibiotics (choice D) is not recommended for preventing pressure ulcers as it does not address the root cause of the problem and can lead to antibiotic resistance. Therefore, the priority intervention should be to use pressure-relieving support surfaces to minimize the risk of pressure ulcers in