Nokea
The nurse assists a client with Parkinson's disease to ambulate in the hallway. The client appears to 'freeze' and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond?
- A. Plan to assess the client's cognition after returning to the room.
- B. Confirm that this is an effective technique to help with ambulation.
- C. Assist the client to a carpeted area to walk more easily.
- D. Reorient the client to the present location and circumstances.
Correct Answer: B
Rationale: Confirming that the client's technique of pretending to step over a crack is an effective strategy acknowledges the client's self-initiated coping mechanism for freezing episodes, which can help promote independence in ambulation.
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A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?
- A. Palpitations and shortness of breath.
- B. Bradycardia and constipation.
- C. Muscle cramping and dry, flushed skin.
- D. Lethargy and lack of appetite.
Correct Answer: A
Rationale: Palpitations and shortness of breath are symptoms of thyrotoxicosis, indicating excessive thyroid hormone levels, which could result from an overdose of levothyroxine.
Initial Assessment
Orders
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue Inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
After administration of medication, the client remains short of breath. Wheezes are noted bilaterally. Oxygen saturation is 91% with supplemental oxygen. Which action(s) should the nurse take next? Select all that apply.
- A. Increase oxygen flow.
- B. Administer additional nebulizer treatment as ordered.
- C. Raise the head of the bed.
- D. Apply a nonrebreather oxygen mask.
- E. Provide client incentive spirometer and instruct on use.
- F. Take and monitor vital signs.
Correct Answer: A,B,C,D,F
Rationale: Increasing oxygen flow, administering additional nebulizer treatment, raising the head of the bed, applying a nonrebreather mask, and monitoring vital signs address persistent respiratory distress and low oxygen saturation.
A client with psoriasis returns to the clinic reporting the persistence of several silvery, scaly areas on the elbows and palms that frequently burn and sometimes bleed. Which prescription should the nurse teach the client to use for the skin condition?
- A. Topical antifungal.
- B. Topical corticosteroids.
- C. Topical analgesics.
- D. Colloidal oatmeal based lotion.
Correct Answer: B
Rationale: Topical corticosteroids are commonly used to reduce inflammation and itching associated with psoriasis, controlling symptoms and promoting healing.
A client presents to the emergency department reporting chest pain that is radiating to the left arm, shortness of breath, and diaphoresis. Which medication should the nurse anticipate being prescribed by the healthcare provider?
- A. Fentanyl.
- B. Hydromorphone.
- C. Morphine.
- D. Oxycodone.
Correct Answer: C
Rationale: Morphine is the medication of choice for managing acute chest pain associated with myocardial infarction. It helps alleviate pain, reduce myocardial oxygen demand, and relieve anxiety.
The nurse is teaching a client with glomerulonephritis about self care. Which dietary recommendation should the nurse encourage the client to follow?
- A. Restrict protein intake by limiting meats and other high protein foods.
- B. Increase intake of high fiber foods, such as bran cereal.
- C. Limit oral fluid intake to 500 mL/day.
- D. Increase intake of potassium rich foods such as bananas or cantaloupe.
Correct Answer: A
Rationale: Restricting protein intake is often recommended for glomerulonephritis to reduce kidney workload and decrease proteinuria, slowing kidney damage progression.