Nokea
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 6 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
For each assessment finding, click to specify if the finding indicates that the client's condition has improved, not changed, or worsened.
- A. Toileting access
- B. Medication organization
- C. Urinary patterns
- D. Activity tolerance
- E. Lower extremities
- F. Bathroom lighting
Correct Answer: A,B,C:Improved;D,E,F:Unchanged
Rationale: Improved toileting access, medication organization, and urinary patterns indicate better management. Activity tolerance, lower extremity symptoms, and bathroom lighting remain unchanged.
You may also like to solve these questions
The nurse is prioritizing caring for four assigned clients. Based on the pulse (P), respiratory rate (R), and blood pressure (BP) provided, which of the clients should the nurse follow up with first?
- A. P: 109; R: 26; BP: 110/70 mmHg
- B. P: 90; R: 12; BP: 99/54 mmHg
- C. P: 100; R: 18; BP: 161/98 mmHg
- D. P: 88; R: 14; BP: 166/52 mmHg
Correct Answer: B
Rationale: BP 99/54 mmHg indicates hypotension, requiring immediate follow-up. Tachycardia/tachypnea, hypertension, and wide pulse pressure are concerning but less urgent.
The nurse is participating in a committee changing the hospital security plan. Which of the following statements by the nurse would be appropriate to make? Select all that apply.
- A. Open visitation should be implemented in the newborn nursery.
- B. Visitors should always wear a badge while in the hospital
- C. Oral temperatures should be obtained for all visitors
- D. Hand sanitizing stations should be offered throughout the facility
- E. Disaster drills should be conducted to ensure staff competency
Correct Answer: B,D,E
Rationale: Visitor badges, hand sanitizing stations, and disaster drills enhance security. Open visitation in nurseries and visitor temperature checks are impractical or unsafe.
The nurse is caring for a client immediately postoperative following a below-the-knee amputation. The nurse should take which priority action?
- A. Elevate the stump on a pillow
- B. Check the operative site for bleeding
- C. Obtain an order for a physical therapy order
- D. Demonstrate the use of incentive spirometry (IS)
Correct Answer: B
Rationale: Checking the operative site for bleeding is the priority to detect hemorrhage, a life-threatening complication in the immediate postoperative period. Elevating the stump may be contraindicated to prevent contractures, physical therapy orders are not immediate, and incentive spirometry, while important, is secondary to hemorrhage control.
The nurse is providing preoperative teaching to a client scheduled for a pneumonectomy. Which of the following statements should the nurse make to the client?
- A. You must lay on your nonoperative side immediately following this surgery
- B. You can expect your lung function to return to normal within two to six hours
- C. You will want to avoid coughing after this surgery as you will be suctioned using a catheter
- D. You will be encouraged to get up and walk the same day as your surgery
Correct Answer: D
Rationale: Early ambulation post-pneumonectomy promotes lung expansion, prevents complications like pneumonia, and aids recovery. Lying on the nonoperative side is not universally required, lung function does not return to normal in hours, and coughing is encouraged to clear secretions, not avoided.
The nurse cares for many clients at the end of life who experience symptoms, such as pain, that are physically distressing to the client and their loved ones. Which statement reflects the American Nurses Association's position on pain management at the end of life?
- A. Advocate for pain management unless life-threatening side effects occur.
- B. Advocate for pain management even if the life-threatening side effects hasten death.
- C. Prohibit the respiratory system from depressing drugs because this is euthanasia.
- D. Allow families to administer respiratory system depressing drugs to hasten death.
Correct Answer: B
Rationale: The ANA supports pain relief at end-of-life, even if side effects like respiratory depression hasten death, prioritizing comfort. Other options misalign with ethical standards.