Nokea
The nurse ensures, which of the following should be present and be cooperative in the educational program?
- A. Patient, student nurses and interns
- B. Patient, family and significant others
- C. Head nurse and family
- D. New staff nurses and nursing aides of the unit
Correct Answer: B
Rationale: In an educational program conducted by a nurse, it is crucial to involve the patient, their family, and significant others. This approach ensures holistic care by considering the patient's psychosocial environment, family dynamics, and support system. Including these individuals in the educational program fosters collaboration, strengthens the patient-nurse relationship, and equips family members with the knowledge and skills needed to provide optimal care at home. Furthermore, involving the patient's support system can enhance adherence to treatment plans and contribute to better health outcomes. Therefore, the presence and cooperation of the patient, family, and significant others are essential elements of a successful educational program led by a nurse.
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One of the patients is manifesting signs and symptoms of alcohol withdrawal such as: tremors, diaphoresis, and hyperactivity. Blood pressure is 190/92 mm.Hg and pulse rate of 92 beats/min. Which of the following medications should you expect to be ordered for these patients?
- A. Lorazepam ( Ativan )
- B. Haloperidol ( Haldol )
- C. Naloxone ( Narcan )
- D. Benztropin ( Cogentin )
Correct Answer: A
Rationale: The patient is exhibiting signs and symptoms of alcohol withdrawal, such as tremors, diaphoresis, hyperactivity, elevated blood pressure, and tachycardia. Lorazepam, which is a benzodiazepine, is commonly used to manage alcohol withdrawal symptoms. It helps alleviate symptoms such as anxiety, agitation, tremors, and seizures by acting on the same brain receptors affected by alcohol. It has sedative, anxiolytic, and anticonvulsant properties which can help stabilize the patient and prevent potential complications of alcohol withdrawal, such as seizures. Haloperidol is an antipsychotic medication used for conditions like schizophrenia and acute psychosis; therefore, it would not be appropriate for alcohol withdrawal. Naloxone is used to reverse opioid overdose, and Benztropin is used to treat Parkinson's disease and extrapyramidal symptoms, so they are not indicated for alcohol
Three hours postpartum, a primiparous patient's fundus is firm and midline. On perineal inspection by Nurse Kayla, she observes a small constant trickle of blood. What will thee nurse suspect for the patient to have?
- A. Uterine inversion
- B. Retained placenta
- C. Perineal lacerations
- D. Bladder distention
Correct Answer: B
Rationale: In this scenario, the firm and midline fundus at three hours postpartum indicates that the uterus is contracting well. The presence of a small constant trickle of blood on perineal inspection suggests ongoing bleeding. This combination of findings is concerning for retained placenta, where a portion of the placenta remains attached to the uterine wall and prevents proper contraction and closure of the blood vessels at the placental site. Retained placenta can lead to postpartum hemorrhage and requires prompt evaluation and intervention to prevent complications. Nurse Kayla should escalate this finding to the healthcare provider for further assessment and management.
Nurse Roberto is aware that a client who has experienced cardiac arrest is MOST at risk for which of the following imbalances?
- A. Metabolic alkalosis
- B. Metabolic acidosis
- C. Respiratory alkalosis
- D. Respiratory acidosis
Correct Answer: D
Rationale: When a client experiences cardiac arrest, their breathing may become insufficient, leading to inadequate elimination of carbon dioxide (CO2) from the body. With reduced CO2 elimination, the level of CO2 in the bloodstream increases, causing respiratory acidosis. This imbalance is characterized by a decrease in blood pH along with an increase in CO2 levels in the blood, resulting in an acidic environment. Respiratory acidosis is the most common imbalance seen in clients who have experienced cardiac arrest, as impaired gas exchange impacts the body's ability to maintain proper acid-base balance.
When the nurse placed the patient in restraints before using other methods of intervention, she/he violated the patient's rights to ______.
- A. receive confidential and respectful care
- B. provide informed consent
- C. receive treatment in the least restrictive environment
- D. refuse treatment
Correct Answer: C
Rationale: Placing a patient in restraints before utilizing other less restrictive interventions violates the patient's right to receive treatment in the least restrictive environment. Restraints should be used as a last resort when all other options have been exhausted, as they can be restrictive to the patient's movement and freedom. Patients have the right to be treated in a manner that minimizes limitations on their personal freedom and autonomy. Restraints should only be utilized when absolutely necessary for the safety of the patient or others.
Which imaging modality is most commonly used to diagnose fractures of the long bones, such as the femur or tibia?
- A. X-ray
- B. Magnetic resonance imaging (MRI)
- C. Computed tomography (CT) scan
- D. Ultrasound
Correct Answer: A
Rationale: X-ray is the most commonly used imaging modality to diagnose fractures of the long bones, such as the femur or tibia. X-rays are readily available, fast, cost-effective, and provide detailed images of the bone structures. Fractures appear as breaks or discontinuities in the bone on X-ray images, making it an excellent tool for diagnosing bone fractures. In many cases, X-rays are sufficient to confirm the presence, location, and type of fracture, allowing for appropriate treatment planning. Other imaging modalities like MRI and CT scans may be used for further evaluation in complex cases, but X-ray remains the initial and primary choice for diagnosing long bone fractures.