Nokea
For each potential action, click to specify if the action is indicated or contraindicated for the client.
- A. Allow the client to watch TV at a high volume.
- B. Ask the client about the content of their hallucinations
- C. Instruct the client on expected hygiene practices.
- D. Assess the client for suicidal ideation.
- E. Place the client in a room near the activity room
Correct Answer: B, C, D indicated; A, E contraindicated
Rationale: Correct Answer: B, C, D indicated; A, E contraindicated
Rationale:
1. B is indicated because asking about hallucinations can help assess the client's mental state.
2. C is indicated as maintaining hygiene is important for the client's well-being.
3. D is indicated to assess and address any suicidal ideation for client safety.
4. A is contraindicated as high TV volume can worsen auditory hallucinations.
5. E is contraindicated as placing near activity room may cause overstimulation and distress.
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A nurse is providing discharge instructions to a client who has a new prescription for haloperidol. Which of the following adverse effects should the nurse instruct the client to report to the provider?
- A. Weight gain
- B. Dry mouth
- C. Shuffling gait
- D. Sedation
Correct Answer: C
Rationale: The correct answer is C: Shuffling gait. Haloperidol is an antipsychotic medication known to cause extrapyramidal side effects like shuffling gait, which can indicate a serious movement disorder called tardive dyskinesia. Reporting this symptom promptly to the provider is crucial for early intervention. Weight gain (A) and dry mouth (B) are common side effects of many medications, including haloperidol, but they are not considered urgent to report. Sedation (D) is a common side effect of haloperidol, but it is not typically a sign of a serious adverse reaction requiring immediate attention.
A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse?
- A. A client who requests assistance to use the bedside commode
- B. A client who has a prescription for compression stockings and did not receive them
- C. A client who requests to sit in the bedside chair while watching TV
- D. A client who consumes all the food from their meal tray
Correct Answer: B
Rationale: Correct Answer: B - A client who has a prescription for compression stockings and did not receive them should be reported to the nurse.
Rationale: Compression stockings are a prescribed medical intervention for a specific reason, such as preventing blood clots or managing edema. Failure to provide them can lead to serious health consequences. The nurse needs to be informed immediately to address this issue promptly.
Summary of Other Choices:
A: A client requesting assistance to use the bedside commode is within the scope of the AP's duties and does not require immediate nurse intervention.
C: A client requesting to sit in a bedside chair is a basic comfort measure and does not require immediate nurse intervention.
D: A client consuming all the food from their meal tray is not a cause for immediate concern and does not require nurse intervention at that moment.
A nurse is caring for a client who is receiving radiation therapy and is experiencing anorexia. Which of the following actions should the nurse take?
- A. Encourage the client to drink low-protein supplements
- B. Tell the client to drink two glasses of water with meals
- C. Serve the client's largest meal in the evening
- D. Provide the client with cold foods rather than hot foods
Correct Answer: D
Rationale: The correct answer is D: Provide the client with cold foods rather than hot foods. Cold foods may be more appealing to a client experiencing anorexia due to radiation therapy, as they often have less strong smells and flavors that can trigger nausea. Cold foods can also help soothe any oral mucositis or mouth sores that may be present. Encouraging the client to eat cold foods can help increase their overall intake and provide necessary nutrients.
Choice A is incorrect because low-protein supplements may not be sufficient in providing necessary nutrients for the client. Choice B is incorrect as simply drinking water with meals may not address the underlying issue of anorexia. Choice C is incorrect as there is no evidence to suggest that serving the largest meal in the evening will improve the client's appetite.
A nurse is inserting an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?
- A. Perform the cleansing procedure with a fresh swab two times
- B. Pick up the catheter 13 cm (5 in) from its tip
- C. Cleanse the tip of the penis in a side-to-side motion
- D. Lift the penis so that it is perpendicular to the client's body
Correct Answer: D
Rationale: The correct answer is D: Lift the penis so that it is perpendicular to the client's body. This action helps in straightening the urethra, making it easier to insert the catheter. Lifting the penis perpendicular to the body also reduces the risk of trauma or injury during catheterization.
A, B, and C are incorrect because performing the cleansing procedure two times with a fresh swab, picking up the catheter 13 cm from its tip, and cleansing the tip of the penis in a side-to-side motion are not recommended practices and may increase the risk of contamination or injury.
The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
- A. Urine protein
- B. Fetal activity
- C. Blood pressure
- D. Urine ketones
- E. Respiratory rate
- F. Report of headache
- G. Gravida/parity
Correct Answer: A, B, C, F
Rationale: The correct answer includes findings that are indicative of potential prenatal complications.
A: Urine protein can indicate preeclampsia, a serious condition in pregnancy.
B: Fetal activity changes may suggest fetal distress or growth restriction.
C: Blood pressure changes can indicate hypertension or preeclampsia.
F: Headache can be a symptom of preeclampsia or other serious conditions.
Choices D, E, and G are not typically associated with prenatal complications. D: Urine ketones may indicate dehydration but not necessarily a prenatal complication. E: Respiratory rate is not directly related to prenatal complications. G: Gravida/parity information is important for obstetric history but not directly indicative of current prenatal complications.