Nokea
The nurse assesses the client every 15 minutes. What objective evidence will the nurse detect that indicates that the restraints are too tight? Select all that apply.
- A. The client reports being unable to move the right hand.
- B. The client's fingers and toes are pale.
- C. The client reports having pain.
- D. Capillary refill is greater than 6 seconds.
- E. There is excoriation around the wrist.
- F. The client reports numbness and tingling.
Correct Answer: B,D,F
Rationale: Pallor, prolonged capillary refill, and numbness indicate impaired circulation, suggesting restraints are too tight and compromising blood flow.
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The client has been placed in restraints for violent behavior. Which statement best indicates the nurse’s understanding of the risk for client injury while being restrained?
- A. “Can you arrange to order the client’s favorite sandwich for his lunch?”
- B. “I need to make sure the restraints’ release mechanisms are working properly.”
- C. “I need someone to continuous monitor the client and relieve me for a few minutes.”
- D. “The client’s feet feel a little cool but they have a good pulse. I’ll get a pair of socks.”
Correct Answer: C
Rationale: Continuous monitoring (C) prevents injury during restraint. Nutrition (A) release mechanisms (B) and circulation checks (D) are secondary to constant observation.
What is the most appropriate nursing action when the terminally ill client's death is imminent?
- A. Stay with the client and contact the family.
- B. Notify the hospital chaplain of the potential for death.
- C. Call the funeral home, alerting them of an imminent death.
- D. Transfer the client to the intensive care unit.
Correct Answer: A
Rationale: Staying with the client provides comfort, and contacting family ensures support, aligning with the advance directive.
The student participating in college sports is suspected of abusing anabolic steroids and is referred to the college’s health service. Which nursing assessment findings are consistent with anabolic steroid abuse? Select all that apply.
- A. Acne vulgaris
- B. Aggressive behavior
- C. Heavy menstruation
- D. Urinary tract infection
- E. Thickening of the hair
- F. Edema of the hands and feet
Correct Answer: A ,B ,D, E
Rationale: Anabolic steroids cause acne (A) aggression (B) UTIs (D) and hair thinning (E not thickening). Heavy menstruation (C) is incorrect; menses cease. Edema (F) may occur but isn’t selected.
The nurse is caring for an unresponsive toddler in a PICU. The child’s parent was arrested for alleged child abuse but released on bail. The parent is pounding at the door belligerent and demanding to visit the child. Which is the most appropriate nursing plan of action?
- A. Allow the parent to enter the room and see the child.
- B. Tell the parent that the HCP wants to speak with the parent first.
- C. Contact Social Services to report the parent’s abusive behavior.
- D. Initiate the emergency response system for behavioral situations.
Correct Answer: D
Rationale: Initiating the emergency response (D) ensures safety. Allowing entry (A) deferring to HCP (B) or reporting to Social Services (C likely already done) are inappropriate.
Which emotional responses are the parents most likely to experience immediately after the sudden death of their infant?
- A. Anger
- B. Guilt
- C. Fear
- D. Depression
Correct Answer: B
Rationale: Guilt is a common immediate response as parents often question their actions or feel responsible for the infant's death, reflecting early grief processing.