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A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?
- A. Encourage the client to discuss their feelings
- B. Establish a plan of care with the client that sets attainable goals
- C. Increase the frequency of physical therapy sessions
- D. Allow the client to set the schedule for rehabilitation
Correct Answer: B
Rationale: The correct answer is B: Establish a plan of care with the client that sets attainable goals. This is because involving the client in setting realistic goals can empower them and increase motivation for rehabilitation. By collaborating with the client, the nurse can address the client's needs and preferences, leading to a more personalized and effective rehabilitation plan. Encouraging the client to actively participate in their care promotes autonomy and fosters a sense of control over their situation.
Other choices are incorrect:
A: Encouraging the client to discuss their feelings is important, but it may not directly address the need for a structured plan of care with attainable goals.
C: Increasing the frequency of physical therapy sessions may be overwhelming for the client and not address the underlying issue of lack of motivation.
D: Allowing the client to set the schedule for rehabilitation may not provide the structure and guidance needed for effective rehabilitation.
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A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will be sure to take the albuterol before taking the cromolyn.
- B. I will take both medications at the same time.
- C. I will take the cromolyn before taking albuterol.
- D. I will take the medications in any order.
Correct Answer: A
Rationale: The correct answer is A: "I will be sure to take the albuterol before taking the cromolyn." This is because albuterol is a bronchodilator that helps to open up the airways quickly, providing immediate relief during an asthma attack. Cromolyn, on the other hand, is a mast cell stabilizer that helps to prevent asthma attacks but does not provide immediate relief. Taking albuterol first allows for quick relief, followed by cromolyn for long-term prevention.
Choice B is incorrect as taking both medications at the same time may not allow for the full effectiveness of each drug. Choice C is incorrect as cromolyn should be taken before albuterol to allow time for it to take effect. Choice D is incorrect as there is a specific order in which these medications should be taken for optimal results.
A nurse is caring for a client who has a cardiopulmonary arrest. The nurse anticipates the emergency response team will administer which of the following medications if the client's restored rhythm is symptomatic bradycardia?
- A. Atropine
- B. Epinephrine
- C. Magnesium
- D. Sodium bicarbonate
Correct Answer: A
Rationale: Rationale: Atropine is the correct answer because it is the first-line medication for symptomatic bradycardia. It works by blocking the parasympathetic nervous system, increasing heart rate. Epinephrine is used for cardiac arrest, not bradycardia. Magnesium is for torsades de pointes, not bradycardia. Sodium bicarbonate is for metabolic acidosis, not bradycardia.
A nurse is assessing a client who reports numbness and pain in his right palm, index finger, and middle finger. The client reports working with a keyboard most of the time while at work. The nurse suspects carpal tunnel syndrome. Which of the following tests should the nurse request that the client perform?
- A. Hold the wrist at a 90-degree flexion.
- B. Perform a straight leg raise test.
- C. Tap the wrist for tenderness.
- D. Hold the arm in an elevated position.
Correct Answer: A
Rationale: The correct answer is A: Hold the wrist at a 90-degree flexion. This test, known as the Phalen's test, is used to assess for carpal tunnel syndrome. By holding the wrist in a flexed position for about 60 seconds, the test can reproduce symptoms of numbness and tingling in the affected fingers. This occurs due to increased pressure on the median nerve, which is characteristic of carpal tunnel syndrome.
Choices B, C, and D are incorrect:
B: Performing a straight leg raise test is used to assess for sciatic nerve irritation in the lower back, not carpal tunnel syndrome.
C: Tapping the wrist for tenderness is not a specific test for carpal tunnel syndrome.
D: Holding the arm in an elevated position is not a recognized test for carpal tunnel syndrome and would not provide relevant information in this context.
A nurse is providing discharge teaching to a client who has a new arteriovenous fistula in the right forearm. Which of the following manifestations should the nurse include in the teaching as a possible indication of venous insufficiency?
- A. Cold and numbness distal to the fistula site
- B. Swelling around the fistula
- C. Bleeding from the fistula
- D. Pain at the site of fistula
Correct Answer: A
Rationale: The correct answer is A: Cold and numbness distal to the fistula site. This is indicative of venous insufficiency, which can occur when the arteriovenous fistula is not functioning properly. When there is inadequate blood flow through the fistula, it can result in reduced circulation to the distal part of the arm, leading to coldness and numbness. Swelling around the fistula (choice B) is more commonly associated with infection or inadequate drainage. Bleeding from the fistula (choice C) is a potential complication but not a typical manifestation of venous insufficiency. Pain at the site of the fistula (choice D) may indicate infection or clotting issues rather than venous insufficiency.
A nurse is instructing a client how to decrease the nausea associated with chemotherapy and radiation. Which of the following statements indicates an understanding of the teaching?
- A. I will eat food that are served at room temperature.
- B. I will eat food that is very hot.
- C. I will drink large amounts of fluids with meals.
- D. I will eat a large meal right before chemotherapy.
Correct Answer: A
Rationale: Correct Answer: A: "I will eat food that is served at room temperature."
Rationale: Eating foods at room temperature can help decrease nausea because hot foods may worsen nausea, while cold foods could cause stomach discomfort. Room temperature foods are generally easier on the stomach and may be better tolerated during chemotherapy and radiation. This choice demonstrates an understanding of how food temperature can impact nausea.
Summary of other choices:
B: Eating very hot food can actually worsen nausea.
C: Drinking large amounts of fluids with meals can dilute stomach acid and enzymes, potentially worsening nausea.
D: Eating a large meal right before chemotherapy can lead to increased nausea and discomfort.