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In planning the nursing care for this patient what is the important nursing intervention a nurse must do?
- A. Encourage patient to release anxiety by crying.
- B. Reassure family that complete recovery is probable.
- C. Assess patient for respiratory distress.
- D. Have patient assist with care.
Correct Answer: C
Rationale: Assessing the patient for respiratory distress is the important nursing intervention that must be done in this situation. The scenario provided indicates that the patient with chronic obstructive pulmonary disease (COPD) is experiencing increased work of breathing, which puts them at risk for respiratory distress. It is crucial for the nurse to monitor the patient's respiratory status closely, including assessing their oxygen saturations, respiratory rate, and effort, to identify any signs of respiratory distress early and intervene promptly. This proactive assessment can help prevent further deterioration of the patient's condition and ensure appropriate nursing interventions are implemented promptly.
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Which nursing intervention constitutes false imprisonment?
- A. A client is hospitalized as an involuntary admission and attempts to leave the unit. The nurse calls the security team per hospital protocol. They prevent the client from leaving.
- B. A psychotic client is admitted as an involuntary client and runs out of the psychiatric unit. The nurse runs after the client and succeeds in talking the client into returning to the unit.
- C. The client has been "pesky," seeking the attention of nurses in the nurses' station much of the day.
- D. The client is confused, combative, and insists that no one can stop him from leaving. The nurse restrains the client without a physician's order, then seeks the order.
Correct Answer: D
Rationale: False imprisonment occurs when a client is physically restrained or confined without legal justification. In this scenario, the nurse restraining the confused and combative client without a physician's order constitutes false imprisonment. Restraints should only be used when necessary to ensure the safety of the client or others, and a physician's order is required to authorize their use. In this case, the nurse acted without proper authorization, making it a violation of the client's rights and false imprisonment. It is essential to follow proper protocols and obtain necessary orders before restraining a client.
A patient presents with sudden-onset severe headache, altered mental status, and focal neurological deficits. Imaging reveals a hemorrhagic lesion within the subarachnoid space. Which of the following neurological conditions is most likely responsible for these symptoms?
- A. Ischemic stroke
- B. Subdural hematoma
- C. Intracerebral hemorrhage
- D. Subarachnoid hemorrhage
Correct Answer: D
Rationale: A subarachnoid hemorrhage is characterized by bleeding within the subarachnoid space, the area between the arachnoid mater and the pia mater surrounding the brain. Patients typically present with a sudden-onset severe headache, altered mental status, and focal neurological deficits due to the mass effect of the blood in the subarachnoid space. Imaging, such as a CT scan, can confirm the presence of the hemorrhagic lesion. Ischemic stroke results from a blockage in the blood vessels supplying the brain, leading to tissue infarction and neurological deficits. Subdural hematoma is a collection of blood between the dura mater and the arachnoid mater, commonly seen following head trauma. Intracerebral hemorrhage involves bleeding within the brain tissue itself, often leading to focal neurological deficits.
Which of the following clinical manifestations will NOT be a complaint from Sarah's condition?
- A. Edema of the extremities
- B. Poor wound healing
- C. Decrease libido
- D. Absence of growth in the pubic area
Correct Answer: C
Rationale: Sarah's condition seems to be related to growth and wound healing issues, based on the provided clinical manifestations. Decrease libido is typically unrelated to conditions like edema, poor wound healing, and absence of growth in the pubic area. Therefore, it would not be a complaint stemming from Sarah's condition.
Which of the following conditions is characterized by inflammation of the tendons surrounding the shoulder joint, leading to pain and restricted movement?
- A. Rotator cuff tear
- B. Adhesive capsulitis (frozen shoulder)
- C. Bursitis
- D. Tennis elbow (lateral epicondylitis)
Correct Answer: C
Rationale: Bursitis is characterized by inflammation of the bursa, which is a small, fluid-filled sac that cushions and reduces friction between bones, tendons, and muscles near joints. In the shoulder, bursitis commonly affects the subacromial bursa, located between the rotator cuff tendons and the top of the shoulder blade. The inflammation of this bursa can lead to pain and restricted movement around the shoulder joint.
A patient presents with a target-like rash with concentric erythematous rings and central clearing on the trunk and extremities. The patient reports recent exposure to a new medication. Which of the following conditions is most likely responsible for this presentation?
- A. Erythema multiforme
- B. Pityriasis rosea
- C. Urticaria (hives)
- D. Seborrheic dermatitis
Correct Answer: A
Rationale: Erythema multiforme is a skin condition characterized by the sudden onset of a target-like rash with concentric erythematous rings and central clearing on the trunk and extremities. It typically presents with a distinctive "iris" or "bull's eye" pattern. Erythema multiforme is often triggered by exposure to certain medications, such as antibiotics, anticonvulsants, and other drugs. The rash is usually accompanied by symptoms like fever, malaise, and joint pain. It is important to identify and discontinue the offending medication causing the reaction in cases of drug-induced erythema multiforme.