Nokea
During electroconvulsive therapy (ECT), the client receives oxygen by mask via positive pressure ventilation. The nurse understands that positive pressure ventilation is necessary for which reason?
- A. Seizure activity depresses respirations.
- B. Anesthesia is routinely administered during the ECT procedure.
- C. Muscle relaxants are given to prevent injury during the seizure.
- D. Decreased oxygen to the brain increases confusion and disorientation.
Correct Answer: C
Rationale: A short-acting skeletal muscle relaxant is administered during this procedure to prevent injuries during the seizure. The client receives positive pressure ventilation until the muscle relaxant is metabolized, usually within 2 to 3 minutes. The remaining options do not address the specific reason for positive pressure ventilation.
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Which of the following laboratory tests should the nurse monitor when the client is receiving warfarin sodium (Coumadin) therapy?
- A. Partial thromboplastin time (PTT).
- B. Serum potassium.
- C. Arterial blood gas (ABG) values.
- D. Prothrombin time (PT).
Correct Answer: D
Rationale: Warfarin therapy requires monitoring prothrombin time (PT) to assess anticoagulation effectiveness.
A client is in the advanced stages of osteoarthritis. Which of the following best describes the pain that occurs in the advanced stage of the disease?
- A. Pain occurs with minimal activity.
- B. Crepitation develops and intensifies pain.
- C. Joints are symmetrically affected by pain.
- D. Fatigue accompanies pain.
Correct Answer: A
Rationale: In advanced osteoarthritis, pain occurs with minimal activity due to significant joint damage and inflammation.
A client who is a computer operator has developed carpal tunnel syndrome. The nurse can instruct the client to relieve the pain by managing:
- A. Decreased circulation to the brachial nerve.
- B. Muscle atrophy resulting from disuse.
- C. Median nerve compression.
- D. Progressive flexion contracture of the wrist.
Correct Answer: C
Rationale: Carpal tunnel syndrome results from median nerve compression, and managing this (e.g., with splints or exercises) relieves pain.
A 6-month-old has had a pyloromyotomy to correct a pyloric stenosis. Three days after surgery, the parents have placed their infant in his own infant seat (see fi gure). The nurse should do which of the following?
- A. Reposition the infant to the left side.
- B. Ask the parents to put the infant back in his crib
- C. Remind the parents that the infant cannot use a pacifier now.
- D. Tell the parents they have positioned their infant correctly
Correct Answer: D
Rationale: Following pyloromyotomy the infant should be positioned with the head elevated and slightly on the right side to promote gastric emptying; the parents have positioned their infant correctly. The infant should be positioned on the right side, not the left side. When the child is in a crib, the head can be elevated and the infant can be propped on the right side. The infant can use a pacifi er if needed.
The nurse is caring for a client with a spinal cord injury at C5. Which complication should the nurse monitor for?
- A. Respiratory distress
- B. Urinary retention
- C. Pressure ulcers
- D. All of the above
Correct Answer: D
Rationale: A C5 spinal cord injury can cause respiratory distress (diaphragm impairment), urinary retention (loss of bladder control), and pressure ulcers (immobility), requiring comprehensive monitoring.