Nokea
Complete the following sentence by using the list of options. The client is at risk of----- as evidenced by-------
- A. fluid volume overload
- B. anemia
- C. hypostatic pneumonia
- D. calorie deficiency
- E. orthostatic hypotension
- F. immobility
Correct Answer: C,F
Rationale: Immobility increases the risk of hypostatic pneumonia, especially in clients with paraplegia.
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The nurse should identify that which of the following client findings requires follow-up care?
- A. A client who is taking bumetanide and has a potassium level of 3.6 mEq/L
- B. A client who is scheduled for a colonoscopy and is taking sodium phosphate
- C. A client who is taking warfarin and has an INR of 1.8
- D. A client who received a Mantoux test 48 hr ago and has an induration
Correct Answer: C
Rationale: The correct answer is C. A client taking warfarin with an INR of 1.8 requires follow-up care as the INR is subtherapeutic, increasing the risk of clot formation. A therapeutic INR for clients on warfarin is typically between 2-3. Options A, B, and D do not require immediate follow-up care. A potassium level of 3.6 mEq/L is within the normal range. Sodium phosphate for a colonoscopy preparation is appropriate. An induration after a Mantoux test is an expected finding.
A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community. Which of the following actions should the nurse plan to take?
- A. Act as a liaison between the facility and the media:
- B. Recommend to the provider specific acute care clients for discharge.
- C. Determine the medical needs of incoming clients through the emergency department
- D. Call in additional medical surgical unit nursing care staff.
Correct Answer: C
Rationale: Correct Answer: C
Rationale: The nurse should plan to determine the medical needs of incoming clients through the emergency department during a mass casualty event to prioritize care based on severity. This action allows for efficient allocation of resources and timely treatment for those in critical condition. Acting as a liaison with the media (A) is not a priority during such emergencies. Recommending clients for discharge (B) is inappropriate as the focus should be on incoming patients. Calling in additional staff (D) may be necessary but determining medical needs is the immediate priority.
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.
Which of the following statements should the nurse make?
- A. We can review some information to help you select a safe alternative practitioner.
- B. I there are therapies available to you, your provider will tell you about them.
- C. Feel free to try whatever therapies that fit within your personal belief system.
- D. I'm sure you can find alternative remedies through an online support group.
Correct Answer: A
Rationale: The correct answer is A because the nurse should offer to review information to assist the patient in selecting a safe alternative practitioner, showing support and guidance. Choice B is incorrect because it assumes the provider will inform the patient of therapies, not necessarily the nurse. Choice C is incorrect as it lacks professional guidance and may lead to unsafe choices. Choice D is incorrect as it suggests the patient can find remedies independently without professional advice.
A nurse is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan of care?(Select all that apply.)
- A. Give the client one simple direction at a time
- B. Refute the client's delusions using logic
- C. Allow the client to choose among a variety of activities each day
- D. Reinforce orientation to time, place, and person
- E. Establish eye contact when communicating with the client.
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
A: Giving the client one simple direction at a time is essential for someone with dementia to reduce confusion and facilitate understanding.
D: Reinforcing orientation to time, place, and person helps maintain the client's sense of reality and reduce disorientation.
E: Establishing eye contact when communicating with the client enhances connection and understanding, aiding in effective communication.
Incorrect Choices:
B: Refuting the client's delusions using logic may lead to frustration and agitation, as individuals with dementia may not be able to understand or accept logical arguments.
C: Allowing the client to choose among a variety of activities each day may overwhelm them with choices, leading to increased confusion and agitation.