Nokea
All of the following clients need attention. Which one should the nurse go to first?
- A. The nursing assistant reports that a client who had a T3 spinal cord transection several months ago has a severe headache and blurred vision.
- B. The nursing assistant needs help turning a client who had a CVA.
- C. The physician is about to examine a client who has multiple sclerosis and requests that the nurse be present.
- D. A client who has amyotrophic lateral sclerosis needs help with ambulating.
Correct Answer: A
Rationale: Severe headache and blurred vision in spinal cord injury suggest autonomic dysreflexia, a life-threatening emergency, prioritizing immediate attention over turning, examination, or ambulation.
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A client asks the nurse about including her 2 and 12 year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
- A. Focus on your sons' needs during the first days at home.
- B. Tell each child what he can do to help with the baby.
- C. Suggest that your husband spend more time with the boys.
- D. Ask the children what they would like to do for the newborn.
Correct Answer: A
Rationale: In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn.
The nurse is caring for a client with a fiberglass cast applied to a distal fracture of the right tibia. The client should be able to bear weight on the cast within:
- A. 10 minutes
- B. 30 minutes
- C. 3 hours
- D. 24 hours
Correct Answer: D
Rationale: Fiberglass casts typically require 24 hours to fully dry and harden before weight-bearing. Choices A, B, and C are too short for the cast to achieve sufficient strength.
The nurse is caring for a postoperative client who is unresponsive to painful stimuli and is given naloxone. Within 5 minutes, the client can be roused and responds to verbal commands. One hour later, the client is again difficult to rouse, with minimal response to physical stimuli. Which actions does the nurse anticipate? Select all that apply.
- A. Administration of oxygen
- B. Administration of a 2nd dose of naloxone
- C. Discontinuation of pain medication
- D. Initiation of a rapid response or code team
- E. Monitoring of respiratory rate
Correct Answer: A,B,E
Rationale: Recurrent unresponsiveness suggests opioid re-narcotization, requiring oxygen, a second naloxone dose, and respiratory monitoring. Discontinuing pain medication is premature, and rapid response is not yet indicated.
A client with aortic stenosis is scheduled for surgery in 2 weeks. The client reports episodes of angina and passing out twice at home. Which would be the best response by the nurse to explain the appropriate activity for this client at this time?
- A. Avoid strenuous activity before the surgery
- B. Continue to exercise, even if angina occurs. It will strengthen your heart muscles
- C. Take short walks 3 times a day
- D. There are no activity restrictions unless angina occurs
Correct Answer: A
Rationale: Strenuous activity risks syncope or ischemia in aortic stenosis, so avoidance is critical. Exercise despite angina is dangerous, short walks may still trigger symptoms, and no restrictions ignore risks.
The nurse on the mental health unit is leading a group session. Shortly after the session begins, a newly admitted client with schizophrenia stands and starts to leave the room. Which of the following actions should the nurse take?
- A. In a loud, firm voice, direct the client to come back to the room
- B. Gently grasp the client's arm and redirect the client back to the seat
- C. Reinforce the unit rules and importance of attending group sessions
- D. Remain silent and allow the client to leave the room with another staff member
Correct Answer: D
Rationale: Allowing the client to leave with another staff member respects their distress and ensures safety, avoiding confrontation. Loud commands, physical redirection, or rule enforcement may escalate agitation.