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The nurse and an unlicensed assistive personnel (UAP) are caring for a client with right-sided paralysis. Which action by the UAP requires the nurse to intervene?
- A. The assistant places a gait belt around the client's waist prior to ambulating.
- B. The assistant places the client on the back with the client's head to the side.
- C. The assistant places a hand under the client's right axilla to move up in bed.
- D. The assistant praises the client for attempting to perform ADLs independently.
Correct Answer: C
Rationale: Placing a hand under the axilla (C) to move a client with right-sided paralysis risks shoulder subluxation or injury to the weak side. A gait belt (A) is appropriate for safe ambulation, positioning with head to the side (B) prevents aspiration, and praising independence (D) is therapeutic.
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The nurse has written a care plan for a client diagnosed with a brain tumor. Which is an important goal regarding self-care deficit?
- A. The client will maintain body weight within two (2) pounds.
- B. The client will execute an advance directive.
- C. The client will be able to perform three (3) ADLs with assistance.
- D. The client will verbalize feeling of loss by the end of the shift.
Correct Answer: C
Rationale: A realistic goal for self-care deficit is performing ADLs with assistance (C), addressing functional limitations due to the tumor. Weight maintenance (A), advance directives (B), and verbalizing loss (D) are not directly related to self-care.
The nurse caring for a client who has been abusing amphetamines writes a problem of 'cardiovascular compromise.' Which nursing interventions should be implemented?
- A. Monitor the telemetry and vital signs every four (4) hours.
- B. Encourage the client to verbalize the reason for using drugs.
- C. Provide a quiet, calm atmosphere for the client to rest.
- D. Place the client on bedrest and a low-sodium diet.
Correct Answer: A,C
Rationale: Amphetamine abuse can cause tachycardia and hypertension. Monitoring telemetry and vital signs (A) detects cardiovascular changes, and a calm atmosphere (C) reduces stimulation. Verbalizing reasons (B) is psychosocial, and bedrest/low-sodium diet (D) is not indicated.
The nurse in the ED documents that the newly admitted client is 'postictal upon transfer.' What did the nurse observe?
- A. Yellowing of the skin due to a liver condition
- B. Drowsy or confused state following a seizure
- C. Severe itching of the eyes from an allergic reaction
- D. Abnormal sensations including tingling of the skin
Correct Answer: B
Rationale: Jaundice and icterus are terms for yellowing of the skin. The client had experienced a tonic-clonic seizure recently and is now in a state of deep relaxation and is breathing quietly. During this period the client may be unconscious or awaken gradually, but is often confused and disoriented. Often the client is amnesic regarding the seizure. Pruritus is a term for itching. Paresthesia is the term for abnormal sensations such as tingling and burning of the skin.
The nurse’s client with a T2 SCI is dysreflexic and has a BP of 170/90 mm Hg. Place the nurse’s interventions in the order that these should be performed.
- A. Elevate the HOB to 90 degrees.
- B. Lower the end of the bed so feet are dependent.
- C. Remove elastic stocking and other constricting devices; assess below the level of injury.
- D. Retake the blood pressure after being upright for 2 to 3 minutes.
- E. Administer a pm prescribed sublingual nifedipine for continued elevated BP.
- F. Perform digital removal of impacted stool (last BM found to be 10 days ago).
- G. Inform the HCP of the incident, measures taken, and client response.
Correct Answer: C,A,B,G,F,E,D
Rationale: Elevate the HOB to 90 degrees. This initial quick action may help lower the client’s BP. Lower the end of the bed so feet are dependent. Placing the feet lower than the head will help decrease blood return and may help lower the BP. Remove elastic stocking and other constricting devices; assess below the level of injury. Anything constricting below the level of injury can be the stimulus that precipitates autonomic dysreflexia. The nurse can assess for other precipitating factors, such as a full bladder, while removing constricting devices. Retake the BP after being upright for 2 to 3 minutes. Elevating the HOB, lowering the feet, and removing constricting devices may have lowered the BP. If not, further interventions are needed. Administer a pm prescribed sublingual nifedipine for continued elevated BP. If the BP remains elevated, the prescribed antihypertensive medication, such as nifedipine (Procardia), should be given next to quickly lower the BP. Perform digital removal of impacted stool (last BM found to be 10 days ago). Digitally removing stool impaction may cause a further spike in BP, so that should be completed after the BP medication is administered. Inform the HCP of the incident, measures taken, and client response. This is last because a pro antihypertensive medication had already been prescribed. Care of the client is priority.
The occupational health nurse is concerned about preventing occupation-related acquired seizures. Which intervention should the nurse implement?
- A. Ensure that helmets are worn in appropriate areas.
- B. Implement daily exercise programs for the staff.
- C. Provide healthy foods in the cafeteria.
- D. Encourage employees to wear safety glasses.
Correct Answer: A
Rationale: Helmets (A) protect against head injuries, a common cause of acquired seizures in occupational settings. Exercise (B), diet (C), and safety glasses (D) do not directly prevent seizures.