Nokea
The chief executive officer (CEO) of a large manufacturing plant presents to the occupational health clinic with chronic rhinitis and requesting medication. On inspection, the nurse notices holes in the septum that separates the nasal passages. The nurse also notes dilated pupils and tachycardia. The facility has a 'No Drug' policy. Which intervention should the nurse implement?
- A. Prepare to complete a drug screen urine test.
- B. Discuss the client’s use of illegal drugs.
- C. Notify the client’s supervisor about the situation.
- D. Give the client an antihistamine and say nothing.
Correct Answer: A
Rationale: Nasal septal perforation, dilated pupils, and tachycardia suggest cocaine use. A drug screen (A) objectively confirms substance use while maintaining confidentiality. Discussing drug use (B) is premature, notifying the supervisor (C) breaches confidentiality, and ignoring findings (D) is unethical.
You may also like to solve these questions
Which intervention is most appropriate for a client with Bell's palsy experiencing eye dryness?
- A. Apply warm compresses to the affected eye.
- B. Administer oral antihistamines.
- C. Use artificial tears as prescribed.
- D. Cover the unaffected eye with a patch.
Correct Answer: C
Rationale: Artificial tears prevent corneal damage from eye dryness in Bell's palsy due to incomplete eye closure.
The nurse is developing a plan of care for a client diagnosed with aseptic meningitis secondary to a brain tumor. Which nursing goal would be most appropriate for the client problem 'altered cerebral tissue perfusion'?
- A. The client will be able to complete activities of daily living.
- B. The client will be protected from injury if seizure activity occurs.
- C. The client will be afebrile for 48 hours prior to discharge.
- D. The client will have elastic tissue turgor with ready recoil.
Correct Answer: B
Rationale: Altered cerebral perfusion in meningitis may lead to seizures. Protecting from injury during seizures (B) addresses this risk. ADLs (A), fever (C), and tissue turgor (D) are unrelated to perfusion.
The nurse is planning the care for a client diagnosed with Parkinson’s disease. Which would be a therapeutic goal of treatment for the disease process?
- A. The client will experience periods of akinesia throughout the day.
- B. The client will take the prescribed medications correctly.
- C. The client will be able to enjoy a family outing with the spouse.
- D. The client will be able to carry out activities of daily living.
Correct Answer: D
Rationale: A therapeutic goal for Parkinson’s disease is to maximize functional ability, such as carrying out ADLs (D). Akinesia (A) is a symptom to minimize, medication adherence (B) is a means to the goal, and family outings (C) are less specific.
The client is diagnosed with ALS. Which client problem would be most appropriate for this client?
- A. Disuse syndrome.
- B. Altered body image.
- C. Fluid and electrolyte imbalance.
- D. Alteration in pain.
Correct Answer: A
Rationale: ALS causes progressive muscle weakness, leading to disuse syndrome (A) from immobility. Body image (B) is secondary, fluid/electrolyte issues (C) are not primary, and pain (D) is less common.
The nurse is caring for clients on the rehabilitation unit. Which clients should the nurse assess first after receiving the change-of-shift report?
- A. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs.
- B. The client with an L4 SCI who is crying and very upset about being discharged home.
- C. The client with an L2 SCI who is complaining of a headache and feeling very hot.
- D. The client with a T4 SCI who is unable to move the lower extremities.
Correct Answer: A
Rationale: Dyspnea and crackles in a C6 SCI patient (A) suggest respiratory compromise, a life-threatening condition requiring immediate assessment. Emotional distress (B), headache (C), or expected paralysis (D) are less urgent.