Nokea
The healthcare provider is caring for a client with a history of hypertension. Which assessment finding would be most concerning?
- A. Blood pressure of 150/90 mmHg
- B. Irregular heart rate
- C. Shortness of breath
- D. Headache
Correct Answer: C
Rationale: Shortness of breath in a client with a history of hypertension is a critical assessment finding as it may indicate heart failure, pulmonary edema, or other severe complications. The development of shortness of breath suggests that the client's condition may be rapidly deteriorating and requires immediate medical attention. Elevated blood pressure (150/90 mmHg) is concerning but not as acute as the potential complications associated with shortness of breath. An irregular heart rate and headache can also be symptoms of hypertension, but in this scenario, shortness of breath poses a higher risk of severe cardiovascular or respiratory issues.
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How should a healthcare professional care for a client approaching death with shortness of breath and noisy respirations?
- A. Turn the client every 2 hours
- B. Provide supplemental oxygen
- C. Use a fan to reduce the feeling of breathlessness
- D. Administer diuretics as prescribed
Correct Answer: C
Rationale: In a palliative care setting, when caring for a client approaching death with symptoms of shortness of breath and noisy respirations, using a fan can help alleviate the sensation of breathlessness. This intervention can provide comfort by improving air circulation and reducing the perception of breathlessness. Turning the client every 2 hours may not directly address the respiratory distress caused by noisy respirations. Providing supplemental oxygen may not be indicated or effective in all cases, especially in end-of-life care where the focus is on comfort rather than aggressive interventions. Administering diuretics as prescribed would not be appropriate for addressing noisy respirations and shortness of breath in a dying client, as this may not be related to fluid overload or congestion. Therefore, the most appropriate action to help the client feel more comfortable in this situation is to use a fan to reduce the feeling of breathlessness.
A client on a telemetry unit is being cared for by a nurse after a myocardial infarction. The client expresses, 'All this equipment is making me nervous.' Which of the following responses should the nurse make?
- A. 'All of this equipment can be frightening.'
- B. 'The equipment is necessary to monitor your condition.'
- C. 'You should try to ignore the equipment.'
- D. 'Try to relax; the equipment is not harmful.'
Correct Answer: A
Rationale: Choice A is the most appropriate response as it acknowledges the client's feelings, showing empathy and understanding. It validates the client's experience, which can help reduce anxiety and build rapport. Choice B provides information but may not address the client's emotional needs. Choice C dismisses the client's concerns and does not offer support. Choice D minimizes the client's feelings and may not effectively address their anxiety.
A nurse prepares an injection of morphine to administer to a client who reports pain but asks a second nurse to give the injection because another assigned client needs to use a bedpan. Which of the following actions should the second nurse take?
- A. Offer to assist the client who needs the bedpan.
- B. Administer the injection the other nurse prepared.
- C. Prepare another syringe and administer the injection.
- D. Tell the client who needs the bedpan to wait while the nurse gives someone else medication.
Correct Answer: C
Rationale: The second nurse should prepare a new syringe and administer the medication to ensure proper and timely pain management. Administering another nurse's medication without preparation could lead to errors. Choice A is not the priority as the medication administration should take precedence. Choice B is not recommended as the second nurse should not administer medication prepared by another nurse. Choice D is inappropriate as patient needs should not be compromised for medication administration to another client.
During the stages of dying, a client reaches the point of acceptance. What response should the LPN/LVN expect the client to exhibit?
- A. Apathy
- B. Euphoria
- C. Detachment
- D. Emotionalism
Correct Answer: C
Rationale: During the stages of dying, when a client reaches the point of acceptance, the expected response is 'Detachment.' This is characterized by the individual withdrawing emotionally and psychologically from their surroundings as they come to terms with their impending death. Apathy (Choice A) refers to a lack of interest, enthusiasm, or concern, which is not typically associated with the acceptance stage. Euphoria (Choice B) is an intense feeling of happiness or excitement, which is less likely during the acceptance stage of dying. Emotionalism (Choice D) involves exaggerated or uncontrollable emotional reactions, which are not commonly seen during the acceptance phase.
When assessing a client reporting increased pain after physical therapy, which question should the nurse ask to evaluate the quality of the pain?
- A. Is the pain sharp or dull?
- B. Does the pain radiate to other areas?
- C. Does the pain increase with movement?
- D. Can you rate your pain on a scale of 1 to 10?
Correct Answer: A
Rationale: The correct question to ask when assessing the quality of a client's pain is whether the pain is sharp or dull. This helps in understanding the characteristics of the pain being experienced. Choice B, asking if the pain radiates to other areas, focuses more on pain distribution rather than quality. Choice C, inquiring if the pain increases with movement, pertains to aggravating factors rather than pain quality. Choice D, requesting the client to rate pain on a scale of 1 to 10, is related to pain intensity rather than quality.