Nokea
On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having any pain. The client's vital signs are pulse rate is 125 beats/minute, respiratory rate is 36 breaths/minute, and blood pressure is 166/88 mmHg. Which nursing interventions should the nurse implement? (Select all that apply.)
- A. Reorient to day and time frequently.
- B. Apply soft wrist restraints bilaterally.
- C. Administer a PRN dose of lorazepam.
- D. Turn the television on for distraction.
- E. Present a calm, supportive demeanor.
Correct Answer: A,C,E
Rationale: Reorienting, administering lorazepam, and presenting a calm demeanor help manage postoperative delirium symptoms like hallucinations, ensuring patient safety and comfort.
You may also like to solve these questions
On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having any pain. The client's vital signs are pulse rate is 125 beats/minute, respiratory rate is 36 breaths/minute, and blood pressure is 166/88 mmHg. Which nursing interventions should the nurse implement? (Select all that apply.)
- A. Reorient to day and time frequently.
- B. Apply soft wrist restraints bilaterally.
- C. Administer a PRN dose of lorazepam.
- D. Turn the television on for distraction.
- E. Present a calm, supportive demeanor.
Correct Answer: A,C,E
Rationale: Reorienting to time, administering lorazepam, and maintaining a calm demeanor address anxiety and hallucinations, reducing distress without increasing stimulation or using restraints unnecessarily.
A client asks the nurse for information about how to reduce risk factors for benign prostatic hyperplasia (BPH). Which information should the nurse provide?
- A. Obtain a prostate-specific antigen blood level test.
- B. Take vitamin supplements.
- C. Increase physical activity.
- D. Consume a high protein diet.
Correct Answer: C
Rationale: Increasing physical activity helps maintain a healthy weight and improves pelvic blood flow, reducing BPH risk factors, unlike PSA testing, supplements, or high-protein diets, which lack direct preventive benefits.
A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?
- A. Confirmation of the autoimmune disease process.
- B. Evidence of spread of the disease to the kidneys.
- C. Indication of the onset of joint degeneration.
- D. Representative of a decline in the client's condition.
Correct Answer: A
Rationale: Elevated rheumatoid factor is a marker of the autoimmune process in rheumatoid arthritis, confirming the diagnosis and indicating disease severity, not specific organ involvement or decline.
Which admission assessment findings should the nurse document related to a client who has been diagnosed with Cushing's syndrome?
- A. Husky voice and complaints of hoarseness.
- B. Warm, soft, moist, salmon-colored skin.
- C. Visible swelling of the neck, with no pain.
- D. Central-type obesity, with thin extremities.
Correct Answer: D
Rationale: Central-type obesity with thin extremities is a hallmark of Cushing's syndrome due to cortisol-induced fat redistribution and muscle wasting, making it a key finding to document.
A client with metastatic cancer reports a pain level of 10 on a pain scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Administer analgesics on a fixed and continuous schedule.
- B. Frequently evaluate the client's pain.
- C. Replace transdermal analgesic patches every 72 hours.
- D. Monitor client for break-through pain.
Correct Answer: A
Rationale: A fixed and continuous analgesic schedule ensures consistent pain relief for chronic severe cancer pain, preventing fluctuations and addressing inadequate response to the initial dose.