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A nurse on the inpatient mental health unit is planning care for the client. For each potential provider's prescription, click to specify if the prescription is anticipated or contraindicated for the client.
- A. Encourage the client to avoid napping during the day.
- B. Place the client in a room away from the nurses' station.
- C. Weigh the client each day
- D. Provide the client with high-calorie fluids every hour.
Correct Answer: A,D
Rationale: Anticipated prescriptions include avoiding naps (to regulate sleep) and providing high-calorie fluids (for nutrition). Contraindicated prescriptions include isolating the client (which may worsen agitation) and daily weighing (unnecessary unless monitoring weight gain/loss).
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Which of the following actions should the nurse take?
- A. Keep visitors at least 6 feet(1.8 m) away from the client.
- B. Place the client's soiled bed linens in a biohazard bag outside the client's room.
- C. Wear an isolation gown when caring for the client.
- D. Discard the radioactive source in the client's trash can.
Correct Answer: B
Rationale: The correct answer is B: Place the client's soiled bed linens in a biohazard bag outside the client's room. This is the correct action to prevent the spread of infection, as soiled linens may contain infectious agents. Keeping visitors 6 feet away (choice A) is related to social distancing, not linens handling. Choice C, wearing an isolation gown, is important but not directly related to handling soiled linens. Discarding a radioactive source in the trash can (choice D) is unsafe and violates radiation safety protocols.
The nurse should identify the cardiac rhythm as which of the following?
- A. Ventricular asystole
- B. Second-degree heart block
- C. Sinus Tachycard
- D. Atrial fibrillation
Correct Answer: D
Rationale: The correct answer is D: Atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to an irregular and rapid heart rate. This can be identified on an ECG by the absence of distinct P waves and irregular R-R intervals. Ventricular asystole (A) is the absence of ventricular contractions, second-degree heart block (B) is characterized by intermittent conduction block between the atria and ventricles, and sinus tachycardia (C) is a regular rapid heart rate originating from the sinus node.
Which pain management technique should the nurse suggest?
- A. Provide information about the use of hydrotherapy during labor
- B. Encourage the use of breathing techniques to manage pain.
- C. Suggest the use of massage or counterpressure to relieve discomfort.
- D. Recommend positioning changes, such as walking or rocking, to ease pain.
- E. Support the use of relaxation techniques, such as visualization, to reduce stress.
Correct Answer: B
Rationale: The correct answer is B: Encourage the use of breathing techniques to manage pain. Breathing techniques help in pain management by promoting relaxation, reducing anxiety, and increasing oxygen flow. This can help the laboring individual cope better with contractions. Other choices are less effective for pain management in labor. A: Hydrotherapy can be beneficial, but breathing techniques are more universally applicable. C: Massage and counterpressure can help, but may not be as effective as breathing techniques during labor. D: Positioning changes are helpful, but breathing techniques are more directly focused on pain management. E: Relaxation techniques like visualization are useful, but breathing techniques are more specifically targeted at managing pain.
Which actions should the nurse take to address suspicion of elder abuse?
- A. Privately interview the client about the injuries
- B. Document the injuries in detail, including size, location, and appearance.
- C. Report the findings to the appropriate authorities, following facility protocol.
- D. Take photographs of the injuries if permitted, as part of the documentation process.
- E. Ensure that the client is not left alone with the suspected abuser during the interview or assessment.
Correct Answer: A,B,C,D,E
Rationale: The correct actions to address suspicion of elder abuse are A, B, C, D, and E.
A: Privately interviewing the client allows for open communication and confidentiality.
B: Documenting injuries in detail provides objective evidence for reporting and potential legal action.
C: Reporting findings to authorities is crucial to protect the elder and comply with legal obligations.
D: Taking photographs, if permitted, supports documentation and investigation.
E: Ensuring the client is not left alone with the suspected abuser protects the client during the assessment. Each action plays a crucial role in addressing elder abuse comprehensively.
Which of the following infection control precautions should the nurse take?
- A. Remove the protective gown while in the client's room.
- B. Place the client in a private room with contact precautions.
- C. Perform hand hygiene using an alcohol-based sanitizer.
- D. Wear an N95 mask when entering the client's room.
Correct Answer: B
Rationale: The correct answer is B: Place the client in a private room with contact precautions. This is the most appropriate infection control measure for preventing the spread of infections. Placing the client in a private room helps to prevent transmission to other individuals. Contact precautions involve using gloves and gowns when in contact with the client or their environment, further reducing the risk of transmission. Choices A, C, and D are incorrect. Removing the protective gown while in the client's room (A) increases the risk of contamination. Hand hygiene using an alcohol-based sanitizer (C) is important but alone is not sufficient for contact precautions. Wearing an N95 mask when entering the client's room (D) is not necessary unless the client has airborne precautions.