Nokea
An elderly client with limited mobility reports feeling isolated and lonely. Which intervention should the nurse prioritize?
- A. Arrange for regular visits from a home health aide
- B. Suggest the client join a local senior center
- C. Refer the client to a support group for seniors
- D. Recommend that the client engage in a new hobby
Correct Answer: B
Rationale: The correct answer is to suggest the client join a local senior center. Joining a local senior center provides the elderly client with opportunities for social interaction, engagement in activities, and access to support systems, which can significantly help alleviate feelings of isolation and loneliness. Regular visits from a home health aide (Choice A) may provide physical assistance but may not address the client's need for social connection. Referring the client to a support group for seniors (Choice C) is beneficial, but joining a senior center offers a wider range of activities and social opportunities. Recommending a new hobby (Choice D) may be helpful, but the priority should be addressing the client's immediate need for social interaction and support.
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A client with a history of seizures is admitted with status epilepticus. Which medication should the nurse prepare to administer?
- A. Phenytoin (Dilantin)
- B. Diazepam (Valium)
- C. Lorazepam (Ativan)
- D. Carbamazepine (Tegretol)
Correct Answer: C
Rationale: In the management of status epilepticus, the initial medication of choice is a benzodiazepine to rapidly terminate the seizure activity. Lorazepam (Ativan) is preferred over Diazepam (Valium) due to its longer duration of action and lower risk of respiratory depression. Phenytoin (Dilantin) and Carbamazepine (Tegretol) are not the first-line agents for the acute treatment of status epilepticus, making them incorrect choices in this scenario.
A community health nurse is conducting a neighborhood discussion group about disaster planning. What information regarding transmission of anthrax should the nurse provide to the group?
- A. Infection is acquired when anthrax spores enter a host.
- B. Mature anthrax bacteria live dormant on inanimate objects.
- C. Spores cannot survive for extended periods outside a living host.
- D. Anthrax is transmitted by respiratory droplets from person to person.
Correct Answer: A
Rationale: The correct answer is A: Infection is acquired when anthrax spores enter a host. Anthrax is primarily transmitted through spores entering the body, either through the skin, inhalation, or ingestion. Person-to-person transmission of anthrax is extremely rare and not a significant mode of transmission. Choices B and C are incorrect because mature anthrax bacteria do not live dormant on inanimate objects, and spores can survive for extended periods outside a living host. Choice D is incorrect as anthrax is not transmitted by respiratory droplets from person to person.
A client who has been receiving chemotherapy for cancer has a platelet count of 20,000/mm3. Which intervention should the nurse include in the plan of care?
- A. Apply ice packs to bruised areas.
- B. Encourage frequent oral hygiene.
- C. Avoid invasive procedures.
- D. Place the client in a private room.
Correct Answer: C
Rationale: The correct intervention for a client with a platelet count of 20,000/mm3 due to chemotherapy is to avoid invasive procedures. Chemotherapy can cause a decrease in platelet count, leading to an increased risk of bleeding. By avoiding invasive procedures, the nurse helps reduce the risk of bleeding complications. Applying ice packs to bruised areas (Choice A) may further increase the risk of bleeding due to the pressure and potential trauma to the skin. Encouraging frequent oral hygiene (Choice B) is important for overall health but does not directly address the risk of bleeding associated with a low platelet count. Placing the client in a private room (Choice D) is not directly related to managing the platelet count and risk of bleeding; it is more about privacy and infection control, which are important but not the priority in this scenario.
A client with a history of deep vein thrombosis (DVT) is admitted with unilateral leg swelling. Which intervention should the nurse implement?
- A. Elevate the affected leg on a pillow.
- B. Apply a warm compress to the affected leg.
- C. Perform passive range-of-motion exercises on the affected leg.
- D. Encourage the client to ambulate frequently.
Correct Answer: A
Rationale: The correct intervention for a client with a history of deep vein thrombosis (DVT) and unilateral leg swelling is to elevate the affected leg on a pillow. Elevating the affected leg helps reduce swelling and pain by promoting venous return and preventing stasis of blood flow. Applying a warm compress (Choice B) may increase inflammation and worsen the condition. Performing passive range-of-motion exercises (Choice C) and encouraging ambulation (Choice D) can dislodge a clot and lead to potential embolism, making these choices contraindicated in a client with DVT.
The home health nurse visits a young male client with AIDS who has Kaposi's sarcoma and peripheral neuropathies. His parents, who are the caregivers, tell the nurse that their son sleeps most of the time. The nurse assesses that the client is semi-conscious with stable vital signs, cries out in pain when turned or moved, has a Duragesic pain patch in place, and skin lesions that are closed and dried. Which intervention should the nurse implement?
- A. remove the Duragesic patch as directed by the prescription
- B. give the client a complete bed bath to further assess the client's condition
- C. discuss end-of-life decisions with the client's parents
- D. call for ambulance transportation to the hospital immediately
Correct Answer: C
Rationale: In this scenario, the client with AIDS is showing signs of being in a critical condition - semi-conscious, in pain, and with stable vital signs. The appropriate intervention for the nurse to implement is to discuss end-of-life decisions with the client's parents. Given the client's symptoms, the presence of a pain patch, and the closed and dried skin lesions, it is essential to address end-of-life care planning. Removing the Duragesic patch without proper authorization can lead to inadequate pain management and should not be done without consulting the healthcare provider. Giving a complete bed bath is not the priority in this situation as it does not address the immediate needs of the client. Calling for ambulance transportation to the hospital immediately may not be necessary if the client is stable; instead, the focus should be on providing appropriate support and having critical discussions about the client's care preferences.