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During an admission assessment, a healthcare professional finds a client's radial pulse rate to be 68/min and the simultaneous apical pulse to be 84/min. What is the client's pulse deficit (per minute)?
- A. 16
- B. 12
- C. 6
- D. 14
Correct Answer: A
Rationale: The pulse deficit is calculated by finding the difference between the apical and radial pulse rates. In this case, the difference is 84 - 68 = 16. This indicates that there is a pulse deficit of 16 beats per minute. Choices B, C, and D are incorrect as they do not accurately reflect the difference between the two pulse rates.
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A nurse is evaluating teaching about nutrition with the guardians of an 11-year-old child. Which of the following statements should indicate to the nurse an understanding of the teaching?
- A. "Our child wants to eat as much as we do, but we're afraid it will lead to becoming overweight."
- B. "Our child skips lunch sometimes, but we figure it's okay as long as we eat a healthy breakfast and dinner."
- C. "We limit fast-food restaurant meals to three times a week now."
- D. "We reward school achievements with a point system instead of pizza or ice cream."
Correct Answer: D
Rationale: The correct answer is D. Rewarding school achievements with a point system rather than food items like pizza or ice cream is a healthier approach. This choice indicates an understanding of the teaching about nutrition and the importance of not using food as a reward. Choices A, B, and C do not demonstrate a clear understanding of the teaching as they focus on concerns about overeating, skipping meals, and limiting fast-food consumption but do not address the concept of avoiding food rewards for achievements.
A client with a history of seizures is prescribed phenytoin (Dilantin). What side effect should the healthcare provider report immediately?
- A. Increased appetite
- B. Dry mouth
- C. Nausea and vomiting
- D. Gingival hyperplasia
Correct Answer: D
Rationale: Gingival hyperplasia is a significant side effect associated with phenytoin therapy. It is characterized by an overgrowth of gum tissue, which can lead to issues such as difficulty in speaking, eating, and maintaining proper oral hygiene. This condition can progress rapidly and may require immediate intervention by the healthcare provider to prevent further complications. Increased appetite, dry mouth, and nausea/vomiting are common side effects of various medications, but they are not as urgent or serious as gingival hyperplasia in a client taking phenytoin.
A nurse in an outpatient surgical center is admitting a client for a laparoscopic procedure. The client has a prescription for preoperative diazepam. Prior to administering the medication, which of the following actions is the nurse's priority?
- A. Teaching the client about the purpose of the medication
- B. Giving the medication at the administration time the provider prescribed
- C. Identifying the client's medication allergies
- D. Documenting the client's anxiety level
Correct Answer: C
Rationale: The correct answer is C: Identifying the client's medication allergies. This is the priority action before administering any medication to prevent allergic reactions or adverse effects. Teaching the client about the medication's purpose is important for client understanding but not as critical as ensuring the absence of allergies. While giving medication at the prescribed time is crucial, verifying allergies takes precedence to ensure patient safety. Documenting the client's anxiety level is relevant for holistic care but is not the priority compared to ensuring safe medication administration.
A client reports mild back pain after receiving analgesia 1 hour ago. Which non-pharmacological pain method should the nurse plan to use?
- A. Apply an ice pack to the client's back for 1 hour.
- B. Remove distractions from the client's room.
- C. Instruct the client to take deep rhythmic breaths.
- D. Encourage the client to apply a heating pad for 2 hours at a time.
Correct Answer: C
Rationale: In this scenario, the nurse should instruct the client to take deep rhythmic breaths as a non-pharmacological pain management method. Deep breathing can help the client relax, reduce stress, and manage pain effectively. Applying heat or ice for prolonged periods can lead to tissue damage. Removing distractions can be helpful for promoting relaxation but may not directly address the pain itself.
A client is 24 hours postoperative following an inguinal hernia repair. The client is tolerating clear liquids well, has active bowel sounds, and is expressing a desire for "real food." The nurse tells the client, "I will call the surgeon and ask for a change in diet." The surgeon hears the nurse's report and prescribes a full liquid diet. The nurse used which of the following levels of critical thinking?
- A. Basic
- B. Commitment
- C. Complex
- D. Integrity
Correct Answer: C
Rationale: The nurse demonstrated complex critical thinking by assessing the client's condition, evaluating the need for a change, and making a recommendation to the surgeon. In this scenario, the nurse went beyond simply following instructions or making routine decisions (basic critical thinking). There was a depth of analysis and decision-making involved, showing a higher level of critical thinking than basic or commitment levels. Integrity is about adherence to ethical principles and honesty, not directly related to the critical thinking process.