Nokea
In a long term rehabilitation care unit a client with spinal cord injury complains of a pounding headache. The client is sitting in a wheelchair watching television in the assigned room. Further assessment by the nurse reveals excessive sweating, a splotchy rash, pilomotor erection, facial flushing, congested nasal passages and a heart rate of 50. The nurse should do which action next?
- A. Take the client's respirations, blood pressure (BP), temperature and then pupillary responses
- B. Place the client into the bed and administer the ordered PRN analgesic
- C. Check the client for bladder distention and the client's urinary catheter for kinks
- D. Turn the television off and then assist client to use relaxation techniques
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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You are teaching a client about the patient-controlled analgesia (PCA) planned for post-operative care. Which statement indicates further teaching may be needed by the client?
- A. ''I will be receiving continuous doses of medication.''
- B. ''I should call the nurse before I take additional doses.''
- C. ''I will call for assistance if my pain is not relieved.''
- D. ''The machine will prevent an overdose.''
Correct Answer: B
Rationale: PCA allows patients to self-administer pain medication within prescribed limits, without the need to call the nurse before taking an additional dose. Choice B suggests a misunderstanding of how PCA works, as the patient should be educated that they can self-administer doses within the safety parameters set by the healthcare provider. Choices A, C, and D demonstrate proper understanding of PCA, hence are not indicative of needing further teaching.
A client with a urinary tract infection is receiving ciprofloxacin (Cipro). The nurse should monitor the client for which of the following side effects?
- A. Hypertension
- B. Hypoglycemia
- C. Hyperkalemia
- D. Tendonitis
Correct Answer: D
Rationale: Ciprofloxacin can cause tendonitis and an increased risk of tendon rupture. Monitoring for tendonitis is crucial as it can lead to significant musculoskeletal issues. Choices A, B, and C are incorrect as hypertension, hypoglycemia, and hyperkalemia are not typically associated with ciprofloxacin use.
Which statement specifically describes occupational health nursing?
- A. Involves prevention, recognition, and treatment of injury and illness
- B. All of these
- C. The application of nursing principles in conserving the health of workers in all occupations
- D. Requires special skills in the field of health, education, and counseling
Correct Answer: B
Rationale: The correct answer is B. Occupational health nursing involves all aspects mentioned in the statements: prevention, recognition, treatment of injury and illness, application of nursing principles in conserving workers' health, and the requirement of special skills in health, education, and counseling. Choice A focuses on prevention, recognition, and treatment but does not encompass all aspects of occupational health nursing. Choice C only mentions the application of nursing principles without including prevention and treatment. Choice D specifically highlights the need for special skills but does not cover all the aspects of occupational health nursing.
Refers to the nurses in the local/national health departments or public schools:
- A. Public health nursing
- B. Public health nurse
- C. Registered midwives
- D. Registered nurses
Correct Answer: B
Rationale: The correct term for nurses working in local/national health departments or public schools is 'public health nurse.' This term specifically refers to individual nurses in those settings. Choice A, 'Public health nursing,' is a broader term that refers to the field of nursing focused on improving community health. Choices C and D, 'Registered midwives' and 'Registered nurses,' do not specifically indicate the nurses working in local/national health departments or public schools, making them incorrect.
A person with no known illness whose daily routine consists of walking and following a healthy diet would be best characterized as engaging in which kind of activities?
- A. health balance
- B. disease prevention
- C. health promotion
- D. self-fulfillment
Correct Answer: C
Rationale: The correct answer is C: health promotion. Health promotion activities involve maintaining a healthy lifestyle to prevent illness. In this scenario, the person is actively engaging in behaviors that promote their overall health and well-being, such as walking and following a healthy diet. Choice A, 'health balance,' is vague and does not specifically address the proactive nature of the person's actions. Choice B, 'disease prevention,' while related, focuses more on specific actions taken to prevent diseases rather than the broader concept of promoting overall health. Choice D, 'self-fulfillment,' does not directly relate to the activities described in the question.