Nokea
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress
- A. Teach the client to use self-talk. Ask, “What kind of drugs have you been taking?â€. Reduce external stimuli. Ask,Have you been sick recently?" Engage with the client several times each day to establish trust"
- B. Brief psychotic disorder. Delirium. Anxiety. Substance use disorder.
- C. Ability to care for self. Fearfulness. Suicide risk. Tremulousness. Temperature
- D. Brief psychotic disorder
Correct Answer:
Rationale: Action to Take: Teach the client to use self-talk, Engage with the client several times each day to establish trust; Potential Condition: Anxiety; Parameter to Monitor: Fearfulness, Suicide risk.
Rationale: The correct actions to take for addressing anxiety would be teaching self-talk and building trust through engagement. Fearfulness and suicide risk are relevant parameters to monitor in assessing the client's progress and response to interventions. These choices align with addressing anxiety and ensuring client safety and well-being.
Incorrect Choices:
- A: "Ask, 'What kind of drugs have you been taking?' and 'Have you been sick recently?' are not appropriate actions for addressing anxiety.
- B: Brief psychotic disorder and delirium are not the potential conditions the client is most likely experiencing.
- C: Monitoring ability to care for self and tremulousness are not the most relevant parameters for assessing anxiety.
You may also like to solve these questions
Which of the following instructions should the nurse include in the teaching?
- A. Place tongue on the mouthpiece of the meter
- B. Maintain a semi-Fowler's position during testing
- C. Record the average of the readings.
- D. Blow into the meter as hard and quickly as possible.
Correct Answer: D
Rationale: The correct answer is D because blowing into the meter as hard and quickly as possible ensures accurate lung function test results. This instruction ensures a consistent and forceful flow of air, which is crucial for reliable readings. Option A is incorrect because the tongue should not be placed on the mouthpiece, as this can affect the accuracy of the test. Option B is incorrect as maintaining a semi-Fowler's position is not necessary for this test. Option C is incorrect because recording the average of the readings is not a step in the actual testing process.
Which of the following findings require follow-up?
- A. 30-year-old client at 33 weeks gestation, Gravida 4 Para 3
- B. CBC and urinalysis collected and sent to lab.
- C. Maternal blood type: Rh+
- D. Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks gestation.
- E. Client reports lower back pain and pinkish vaginal discharge.
- F. Uterine contractions every 8 minutes, palpate strong, duration 30 seconds,
- G. FHR baseline 145, minimal variability.
Correct Answer: E,F,G
Rationale: The correct answers are E, F, and G because they indicate potential complications during pregnancy.
E: Lower back pain and pinkish vaginal discharge can be signs of preterm labor or placental issues, requiring immediate follow-up.
F: Uterine contractions every 8 minutes, strong palpation, and duration 30 seconds suggest active labor, needing monitoring for progression.
G: Fetal heart rate (FHR) baseline of 145 with minimal variability may indicate fetal distress, necessitating further assessment.
Other choices are routine findings or do not pose immediate risks, such as A (normal obstetric history), B (routine lab tests), C (Rh+ blood type is common), and D (history of preterm birth but no current concerns).
The nurse should identity which of the following conditions as a contraindication for receiving this treatment?
- A. Hypertension
- B. Obesity
- C. Hypothyroidism
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D. Herpes zoster is a contraindication for certain treatments because it is a viral infection that can worsen with immunosuppressive therapy. Hypertension, obesity, and hypothyroidism are not direct contraindications for receiving the treatment mentioned. Hypertension can be managed, obesity and hypothyroidism do not directly impact the treatment's efficacy. Herpes zoster, on the other hand, can lead to serious complications if the treatment suppresses the immune system. It is crucial to address active infections before starting immunosuppressive therapy to prevent further complications.
A nurse is caring for a client who is in a coma and is scheduled for a surgical procedure. Which of the following actions should the nurse take?
- A. Send the unsigned informed consent form to the facility's risk manager.
- B. Determine if the client's health care surrogate is aware of the risks and benefits of the procedure.
- C. Ensure that the client's family supports the provider's decision for surgery,
- D. Determine if the procedure is medically necessary for the client.
Correct Answer: B
Rationale: The correct answer is B: Determine if the client's health care surrogate is aware of the risks and benefits of the procedure. This is important because the client is in a coma and unable to provide informed consent. The health care surrogate acts on behalf of the client and must be fully informed about the procedure to make decisions in the client's best interest. Sending the unsigned consent form to the risk manager (A) is not appropriate as it does not address the issue of informed consent. Ensuring family support (C) is important but does not address the legal requirement of informed consent. While determining medical necessity (D) is important, in this case, the primary concern is obtaining informed consent.
For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client.
- A. Irrigate indwelling urinary catheter with 50 mL of normal saline:
- B. Administer enema to relieve constipation
- C. Maintain bed rest for 2 days postoperatively
- D. Place a blanket rob under the client's knees while in bed.
- E. Apply warm compresses to the incision site.
Correct Answer:
Rationale: Rationales provided within the question context.