Nokea
A client with severe multiple trauma injuries from a motor vehicle accident.
After stabilizing a client with severe multiple trauma injuries from a motor vehicle accident, which of the following actions by the nurse is BEST?
- A. Limit visiting hours to promote optimal rest.
- B. Arrange for clergy to visit with the client and family as requested.
- C. Arrange for a psychologist to visit with the family.
- D. Arrange for the family to meet with a social worker to discuss financial aid.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) inappropriate (2) correct-would provide the appropriate spiritual support necessary during a crisis (3) inappropriate for the data given in the situation (4) inappropriate for the data given in the situation
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The nurse is caring for a client with a history of hyponatremia.
- A. Which intervention is most appropriate for a client with hyponatremia?
- B. Administer hypertonic saline slowly.
- C. Encourage a low-sodium diet.
- D. Restrict fluid intake.
- E. Administer a diuretic.
Correct Answer: A
Rationale: Administering hypertonic saline slowly corrects hyponatremia by raising serum sodium levels, preventing cerebral edema. Low-sodium diets worsen hyponatremia, fluid restriction is for hypervolemic cases, and diuretics are contraindicated.
The nurse is transcribing the following physician's orders.
Which of the following orders warrants further clarification?
- A. Administer haloperidol (Haldol) 5 mg.
- B. Instruct client to use incentive spirometer q1h while awake.
- C. D5W 1/4 NS + KCl 20 mEq/L at 100 mL/h.
- D. CBC with differential and platelets at 8 AM.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-has no route of administration or schedule (2) clear and complete and needs no further clarification (3) clear and complete and needs no further clarification (4) clear and complete and needs no further clarification
A 5-year-old child has been treated for sickle cell crisis. The parent asks the nurse if there is anything that can be done to prevent future crises. What should be included in the nurse's response?
- A. Sickle crisis is hard to predict and not usually preventable.
- B. Keeping the child from getting chilled may prevent a crisis.
- C. Fevers, vomiting, and diarrhea should be reported to the physician immediately.
- D. Giving the child aspirin on a daily basis lessens the frequency of crises.
Correct Answer: C
Rationale: Fevers, vomiting, and diarrhea can trigger sickle cell crisis by causing dehydration or infection, so prompt reporting allows early intervention to prevent crises.
A fifty-five year-old man suffered a left frontal lobe CVA. The patient's family is not present in the room. Which of the following should the nurse watch most closely for?
- A. Changes in emotion and behavior
- B. Monitor loss of hearing
- C. Observe appetite and vision deficits
- D. Changes in facial muscle control
Correct Answer: A
Rationale: The frontal lobe is responsible for behavior and emotions.
The nurse is caring for an 80-year-old client with Parkinson’s disease.
- A. What is the most realistic and appropriate nursing goal for an 80-year-old client with Parkinson’s disease?
- B. Return the client to usual activities of daily living.
- C. Maintain optimal function within the client’s limitations.
- D. Prepare the client for a peaceful and dignified death.
- E. Arrest progression of the disease process in the client.
Correct Answer: B
Rationale: Parkinson’s disease is progressive and irreversible, so maintaining optimal function within the client’s limitations is the most realistic goal, focusing on mobility, safety, and quality of life. Returning to normal activities, preparing for death, or arresting progression are unrealistic or inappropriate.