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An adolescent girl tells the nurse that she is very suicidal. The nurse asks her whether she has a specific plan. Asking this should be considered:
- A. an appropriate part of the assessment.
- B. not a critical part of the assessment.
- C. suggesting that the adolescent needs a plan.
- D. encouraging the adolescent to devise a plan.
Correct Answer: A
Rationale: Asking an adolescent girl who expresses suicidal thoughts whether she has a specific plan is an appropriate part of the assessment. This question helps the nurse determine the level of risk and urgency of the situation. Knowing whether there is a specific plan in place can guide the nurse in determining the appropriate intervention and level of care needed to ensure the safety and well-being of the adolescent. It is crucial to assess for the presence of a specific plan as it can indicate a higher risk of imminent harm.
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A patient is being given Digoxin to treat heart failure. Which of the ff. is a usual adult daily dosage of digoxin (Lanoxin)?
- A. 0.005 mg
- B. 0.025 mg
- C. 0.25 mg
- D. 2.5 mg
Correct Answer: C
Rationale: The usual adult daily dosage of digoxin (Lanoxin) for the treatment of heart failure typically ranges from 0.125 mg to 0.25 mg. The maintenance dose is specific to each individual patient's needs and is adjusted based on factors such as age, weight, renal function, and the presence of other medical conditions. The dosage prescribed should be carefully determined by a healthcare provider to ensure optimal therapeutic effects and minimize the risk of side effects associated with digoxin. Dosages higher than 0.25 mg are usually not recommended due to the narrow therapeutic index of digoxin. It is essential for patients taking digoxin to have their drug levels monitored regularly to prevent toxicity.
A client is being treated for acute pyelonephritis and will undergo laboratory tests. These tests are expected to help determine the clients BUN, creatinine, and serum electrolyte levels. Why should the nurse evaluate these test results?
- A. To determine the severity of the disorder
- B. To identify signs of fluid retention
- C. To determine the location of discomfort
- D. To determine clients response to therapy
Correct Answer: A
Rationale: Evaluating the client's BUN, creatinine, and serum electrolyte levels when being treated for acute pyelonephritis is crucial in determining the severity of the disorder. BUN and creatinine levels are indicators of renal function, where elevated levels may suggest impaired kidney function due to inflammation in the kidneys from pyelonephritis. Abnormal electrolyte levels, such as potassium and sodium, may also reflect the impact of the infection on renal function. Therefore, monitoring these test results helps healthcare providers assess how well the kidneys are functioning and the severity of the pyelonephritis to guide appropriate treatment decisions.
A 5-year old boy presents with afebrile generalized tonic-clonic seizure lasting for 5 minutes. Previously he was healthy and had no such problem. On examination there is no abnormality. Your plan of management should be:
- A. Start anticonvulsant therapy
- B. Request for an EEG and wait for its report
- C. Request for an EEG and start anticonvulsant therapy immediately
- D. Request for EEG and MRI brain
Correct Answer: C
Rationale: In a first-time generalized seizure, an immediate EEG and starting anticonvulsant therapy is prudent to prevent recurrence, especially if the EEG shows epileptiform activity.
Which of the ff diets does the nurse recommend for clients with hypertension under the physicians guidance?
- A. The Food Guide Pyramid
- B. The South Beach Diet
- C. The Step One Diet
- D. The Dash diet
Correct Answer: D
Rationale: The Dietary Approaches to Stop Hypertension (DASH) diet is recommended by healthcare professionals, including nurses, for clients with hypertension. This diet emphasizes consuming fruits, vegetables, whole grains, lean proteins, and low-fat dairy products while limiting sodium, saturated fats, and cholesterol. These dietary components are known to help lower blood pressure and improve overall health. The DASH diet has been proven effective in numerous studies and is endorsed by organizations like the American Heart Association for managing hypertension. It is important for clients to follow the DASH diet under the guidance of a physician to ensure it is tailored to their individual needs and health status.
When a client is receiving blood which of the ff nursing actions is essential to determine if chilling is the result of an emerging complication or of infusing cold blood?
- A. Monitoring the client's temperature before, during, and after transfusion
- B. Documenting the client's temp after the transfusion
- C. Documenting the temp of the blood before the transfusion
- D. Comparing the client's temp with the temp of the blood
Correct Answer: A
Rationale: Monitoring the client's temperature before, during, and after transfusion is essential to determine if chilling is the result of an emerging complication or of infusing cold blood. By consistently monitoring the client's temperature at different points in the transfusion process, healthcare providers can identify any significant changes that may indicate a complication. This allows for timely intervention and appropriate management of any issues related to the blood transfusion. Comparing the client's temperature with the temperature of the blood is important but alone it may not provide a comprehensive assessment of the client's condition during the transfusion process. So, the best course of action is to monitor the client's temperature at various time points to ensure accurate assessment and early detection of any complications.