Nokea
Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except:
- A. tolerance.
- B. constipation.
- C. sedation.
- D. addiction.
Correct Answer: D
Rationale: Addiction is not of primary concern when treating the pain of terminally ill clients. Clients with cancer who are taking opioid analgesics can develop tolerance, constipation, and sedation.
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The intent of the Patient Self Determination Act (PSDA) of 1990 is to:
- A. enhance personal control over legal care decisions
- B. encourage medical treatment decision making prior to need
- C. give one federal standard for living wills and durable powers of attorney
- D. emphasize client education
Correct Answer: B
Rationale: The PSDA encourages advance directives to promote proactive medical decision-making, ensuring clients' wishes are honored before a crisis.
A nurse is working in a pediatric clinic and a mother brings in her 13 month old child who has Down Syndrome. The mother reports, 'My child's muscles feel weak and he isn't moving well. My RN friend checked his reflexes and she said they are diminished.' Which of the following actions should the nurse take first?
- A. Contact the physician immediately
- B. Have the patient go to X-ray for a c-spine work-up.
- C. Start an IV on the patient
- D. Position the child's neck in a neutral position
Correct Answer: D
Rationale: An atlanto-axial dislocation may have occurred, common in Down Syndrome. Positioning the child's neck in a neutral c-spine posture is the first step to prevent further injury, followed by contacting the doctor.
A pregnant client has congenital heart disease. The nurse should expect to see which alterations in this client's diet during pregnancy?
- A. reduced calories and reduced fat
- B. caffeine and sodium restrictions
- C. decreased protein and increased complex carbohydrates
- D. fluid restriction and reduced calories
Correct Answer: B
Rationale: Caffeine and sodium restrictions are necessary to reduce cardiac strain and fluid retention in a pregnant client with heart disease, avoiding exacerbation of her condition.
The nurse is transferring a client from a wheelchair to the bed. Which is the correct procedure?
- A. Pull the client toward you, and pivot him on the unaffected limb
- B. Pull the client toward you, and pivot him on the affected limb
- C. Push the client toward the bed, and pivot him on the affected limb
- D. Stand the client on both legs, and push him toward the bed
Correct Answer: A
Rationale: Pulling the client and pivoting on the unaffected limb ensures safety and leverages the client's stronger side for support.
The client residing in a nursing home has bilateral weak handgrips and visual and hearing deficits. Which interventions should the nurse implement when the client is eating a meal? Select all that apply.
- A. Ask the client's permission to open containers and cut up meats on the food tray.
- B. Obtain special easy-to-hold, built-up silverware for the client to use when eating.
- C. Observe the client, but avoid providing assistance even if the client is frustrated.
- D. Help feed the client if the client is eating too slowly so food does not get too cold.
- E. Ensure that the client wears eyeglasses and hearing aids before starting to eat.
Correct Answer: A,B,E
Rationale: A: Asking permission promotes autonomy. B: Built-up silverware aids weak grips. E: Sensory aids enhance independence. C: Assistance reduces frustration. D: Feeding discourages independence.