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The elderly male client is admitted to the medical unit with a diagnosis of senile dementia. The client is 74 inches tall and weighs 54.5 kg. The client lives with his son and daughter-in-law, both of whom work outside the house. Which referral is most important for the nurse to implement?
- A. Adult Protective Services.
- B. Social worker.
- C. Medicare ombudsman.
- D. Dietitian.
Correct Answer: A
Rationale: Low weight (54.5 kg for 74 inches, BMI ~16.5) and dementia suggest potential neglect, warranting Adult Protective Services referral. Social work, ombudsman, and dietitian are secondary.
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The elderly client is brought to the ED complaining of cramps, headache, and weakness after working outside in the sun. The telemetry shows sinus tachycardia. Which intervention should the nurse implement?
- A. Determine if the client is experiencing any thirst.
- B. Administer D5W intravenously at 250 mL/hr.
- C. Maintain a cool environment to promote rest.
- D. Withhold the client’s oral intake.
Correct Answer: C
Rationale: Heat exhaustion (suggested by symptoms) requires a cool environment to reduce core temperature. Thirst assessment, D5W, and withholding intake are secondary or incorrect.
The client diagnosed with septicemia has the following health-care provider orders. Which HCP order has the highest priority?
- A. Provide clear liquid diet.
- B. Initiate IV antibiotic therapy.
- C. Obtain a STAT chest x-ray.
- D. Perform hourly glucometer checks.
Correct Answer: B
Rationale: IV antibiotics are critical in septicemia to combat infection, the primary cause. Diet, x-ray, and glucose checks are secondary to infection control.
The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cardiogenic shock?
- A. Monitor the client’s telemetry.
- B. Turn the client every two (2) hours.
- C. Administer oxygen via nasal cannula.
- D. Place the client in the Trendelenburg position.
Correct Answer: C
Rationale: Oxygen administration improves myocardial oxygenation, preventing cardiogenic shock post-MI. Telemetry monitors, turning prevents ulcers, and Trendelenburg is contraindicated.
A nurse is at the lake when a person nearly drowns. The nurse determines the client is breathing spontaneously. Which data should the nurse assess next?
- A. Possibility of drug use.
- B. Spinal cord injury.
- C. Level of confusion.
- D. Amount of alcohol.
Correct Answer: B
Rationale: Spinal cord injury assessment is critical post-near-drowning due to potential diving-related trauma, affecting stabilization. Confusion, drug use, and alcohol are secondary.
The nurse is teaching a class on bioterrorism. Which statement is the scientific rationale for designating a specific area for decontamination?
- A. Showers and privacy can be provided to the client in this area.
- B. This area isolates the clients who have been exposed to the agent.
- C. It provides a centralized area for stocking the needed supplies.
- D. It prevents secondary contamination to the health-care providers.
Correct Answer: D
Rationale: Decontamination areas prevent secondary contamination to HCPs, the primary rationale. Privacy, isolation, and supply stocking are secondary benefits.