Nokea
Before administering a benzodiazepine, what should the nurse assess?
- A. Sleep problems
- B. Memory impairment
- C. Cognitive disorder
- D. Behavior changes
Correct Answer: D
Rationale: Behavioral changes may indicate underlying issues or contraindications for benzodiazepines.
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During an assessment of a patient who sustained a head injury 24 hours ago, the medical-surgical nurse notes the development of slurred speech and disorientation to time and place. The nurse's initial action is to
- A. continue the hourly neurologic assessments.
- B. inform the neurosurgeon of the patient's status.
- C. prepare the patient for emergency surgery.
- D. recheck the patient's neurologic status in 15 minutes.
Correct Answer: B
Rationale: Neurological changes could indicate worsening intracranial pressure, necessitating immediate physician notification.
The old-old population (85 years and older) has an increased risk for frailty. However, old age is just one element of frailty. Identify at least three other assessment findings that contribute to frailty.
- A. Decreased muscle mass
- B. Weight loss
- C. Reduced physical activity
- D. Increasing disability and symptoms
Correct Answer: A
Rationale: Decreased muscle mass, unintentional weight loss, and reduced physical activity are key contributors to frailty in older adults.
A client is in the immediate postoperative period following a partial laryngectomy. Which of the following parameters should the nurse assess first?
- A. Pain severity
- B. Wound drainage
- C. Tissue integrity
- D. Airway patency
Correct Answer: D
Rationale: The correct answer is D: Airway patency. Assessing airway patency is the priority in the immediate postoperative period following a laryngectomy to ensure the client's ability to breathe. If the airway is compromised, it can lead to life-threatening complications. Pain severity (A), wound drainage (B), and tissue integrity (C) are important assessments but are secondary to ensuring the client's airway is clear and functioning properly. Prioritizing airway patency allows for prompt intervention if any issues arise, ensuring the client's safety and optimal recovery.
While suctioning the endotracheal tube of a client on a ventilator, the nurse notices an increase in the client's heart rate from 86/min to 110/min, with irregularity. What should the nurse do next?
- A. Obtain a cardiology consult.
- B. Suction the client less frequently.
- C. Administer an antidysrhythmic medication.
- D. Perform pre-oxygenation prior to suctioning.
Correct Answer: D
Rationale: The correct answer is D: Perform pre-oxygenation prior to suctioning. In this scenario, the increase in heart rate and irregularity could be due to hypoxia resulting from suctioning. Pre-oxygenation helps to ensure adequate oxygenation before the procedure, preventing hypoxia-induced dysrhythmias. By providing oxygen before suctioning, the nurse can minimize the risk of further complications.
Choice A (Obtain a cardiology consult) is incorrect because immediate action is required to address the potential hypoxia, which can be managed by pre-oxygenation.
Choice B (Suction the client less frequently) is incorrect as it does not address the immediate concern of potential hypoxia leading to dysrhythmias.
Choice C (Administer an antidysrhythmic medication) is incorrect as it is not the initial intervention needed in this situation; addressing the underlying cause of potential hypoxia is essential before considering antidysrhythmic medications.
Tom arrives in the Emergency Room (ER) and is unable to move his legs as a result of an automobile accident that occurred 30 minutes ago. You respond by saying
- A. Swelling due to the initial trauma prevents you from moving your legs.
- B. There are good rehabilitation centers that will help restore sensation to your legs.
- C. Swelling due to the initial trauma may make the injury seem more severe than it actually is. A more accurate assessment will be made once the swelling goes down.
- D. You should have been wearing your seatbelt.
Correct Answer: C
Rationale: Initial swelling can mask the true extent of spinal injuries.