Nokea
The nurse has determined that a client with trigeminal neuralgia has the nursing problem, 'Imbalanced nutrition, less than body requirements.' Which cause is most likely contributing to the problem?
- A. Fatigue.
- B. Pain when eating.
- C. Nausea.
- D. Altered taste sensation.
Correct Answer: B
Rationale: Severe facial pain from trigeminal neuralgia deters eating, leading to imbalanced nutrition.
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The nurse assists a client with Parkinson's disease (PD) 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 his room.
- B. Confirm that this is an effective technique to help with ambulation.
- C. Reorient the client to his present location and circumstances.
- D. Assist the client to a carpeted area where he can walk more easily.
Correct Answer: B
Rationale: Pretending to step over an object is a known technique to manage freezing in Parkinson's, aiding ambulation.
Nurses' Notes
Assessment is completed. The nurse notes that the nail angle is 180 degrees when viewed from the side and is spongy when palpated.
The nurse reviews client data. Select the 3 possible conditions that could have the clinical manifestation of clubbed nails for this client.
- A. Pneumonia
- B. Lung cancer
- C. Flu
- D. Chronic obstructive pulmonary disease (COPD)
- E. Chronic bronchitis
Correct Answer: B,E
Rationale: Lung cancer and chronic bronchitis are associated with clubbed nails due to chronic hypoxemia, unlike pneumonia or flu.
A client is receiving a secondary infusion of vancomycin 1,500 mg in 250 ml to be infused over two hours. The IV administration set delivers 15 gtt/mL. How many gtt/min should the nurse regulate the Infusion? (Enter numerical value only. If rounding is required, round to the nearest whole number.)
Correct Answer: 31
Rationale: Using the formula (250 mL x 15 gtt/mL) / 120 min = 31.25 gtt/min, rounded to 31 gtt/min.
History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.
The nurse identifies that the client is having a tonic clonic seizure. The oxygen saturation is 40% and the respiratory rate is 4 breaths/minute. The nurse calls for help and 2 other nurses enter the room. Which 3 interventions should be performed first?
- A. Place pillows around the bed rails to provide padding.
- B. Watch the seizure activity and document the time and client movement.
- C. Manually ventilate the client with a bag-valve mask (BVM).
- D. Stop the IV fluids.
- E. Increase the supplemental oxygen to 10 L/minute via nasal cannula.
- F. Begin chest compressions.
Correct Answer: B,C,E
Rationale: Ventilation, oxygen increase, and seizure monitoring address hypoxia and safety during a tonic-clonic seizure.
A client receiving thyroid replacement therapy following a thyroidectomy is seen in the dinic for a 6 weeks postoperative check-up. Which assessment is most important for the nurse to obtain?
- A. Report of bowel functioning since surgery.
- B. Heart rate and body weight.
- C. Number of any missed doses of medication.
- D. Daily caloric intake.
Correct Answer: B
Rationale: Heart rate and body weight assess thyroid replacement therapy effectiveness, reflecting metabolic rate changes.