Nokea
The nurse in a clinic is triaging clients. Which of the following clients should the nurse see first?
- A. A 17-year-old complaining of abdominal cramping with moderate bloody vaginal discharge
- B. A 25-year-old primigravida reporting blurred vision.
- C. A 50-year-old menopausal client expelling dark red blood clots.
- D. A 70-year-old client who states her uterus is going to 'fall out.'
Correct Answer: B
Rationale: Blurred vision in a 25-year-old primigravida (B) suggests preeclampsia, a life-threatening emergency requiring immediate assessment. Abdominal cramping with bleeding (A), menopausal clotting (C), and uterine prolapse (D) are less urgent, though they require follow-up.
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The nurse in the emergency department (ED) is caring for an unconscious client who sustained a head injury following a motor vehicle crash. The health care provider (HCP) has ordered an emergency surgery. Which action should the nurse take regarding informed consent?
- A. obtain a court order for the surgical procedure in place of an informed consent
- B. search the client's belongings for any identification
- C. transport the client to the operating room for surgery immediately
- D. call the police to report the incident, identify the client, and locate the family
Correct Answer: C
Rationale: For an unconscious client requiring emergency surgery, implied consent applies, allowing immediate transport to the operating room (C) to save life or prevent harm. Court orders (A), searching belongings (B), or calling police (D) delay critical care and are not required for emergency consent.
The nurse is developing a care plan for a client with Bell's palsy. Which problem should the nurse prioritize in the care plan?
- A. Risk for infection
- B. Risk for disturbed sensory perception
- C. Risk for disturbed body image
- D. Risk for ineffective tissue perfusion
Correct Answer: B
Rationale: Risk for disturbed sensory perception (B) is the priority in Bell’s palsy due to facial paralysis, which can lead to corneal abrasion or oral injury. Infection (A), body image (C), and perfusion (D) are secondary concerns.
You are caring for a group of psychiatric mental health clients. One of these clients, who has anger management and aggressive behavior concerns, has not yet gained telephone privileges. You notice an unlicensed assistive personnel (UAP) on the unit escorting this client to the telephone. After you speak to the client about the telephone privileges, the UAP tells you, 'It is unfair for this client not to be able to use the telephone when other clients are free to do so.' What should you determine about this UAP’s comment?
- A. This comment demonstrates that the unlicensed assistive personnel (UAP) favors this client.
- B. This comment indicates that the unlicensed assistive personnel (UAP) is ensuring equal rights.
- C. This comment indicates that the unlicensed assistive personnel (UAP) is preventing discrimination.
- D. This comment indicates a learning need for the unlicensed assistive personnel (UAP) relating to the therapeutic milieu.
Correct Answer: D
Rationale: The UAP’s comment (D) reflects a lack of understanding of the therapeutic milieu, where restrictions like telephone privileges are part of a care plan to manage aggression. It does not indicate favoritism (A), equal rights (B), or anti-discrimination (C), but a need for education on unit protocols.
The nurse is caring for assigned clients. Which of the following clients would be appropriate for the nurse to refer for an interdisciplinary conference? A client with Select all that apply.
- A. pulmonary tuberculosis with multiple prescriptions.
- B. ischemic stroke who has left-sided hemiplegia.
- C. hyperthyroidism and is scheduled for a thyroidectomy.
- D. stage one Alzheimer’s disease who lives with family.
- E. fractured tibia and fibula and is homeless.
- F. end-stage-renal disease who refuses dialysis.
Correct Answer: A, B, E, F
Rationale: TB with multiple drugs (A), stroke with hemiplegia (B), homeless with fractures (E), and dialysis refusal (F) require interdisciplinary coordination due to complex medical, social, or ethical needs. Thyroidectomy (C) and early Alzheimer’s (D) are less complex for conferencing.
The nurse is caring for a client diagnosed with multiple myeloma. The nurse reviews the client's lab values and notes a serum calcium level of 14 mg/dL (3.5 mmol/L) [9-10.5 mg/dL]. What is the priority action the nurse should take?
- A. Notify the primary healthcare provider (PHCP)
- B. Document the finding
- C. Continue to monitor the client
- D. Remove the client from the telemetry monitor
Correct Answer: A
Rationale: Hypercalcemia of 14 mg/dL in multiple myeloma (A) is a medical emergency risking cardiac arrhythmias, requiring immediate PHCP notification. Documentation (B) and monitoring (C) are secondary, and removing telemetry (D) is inappropriate, as monitoring is needed.