Nokea
The nurse is admitting a 56-year-old client with a diagnosis of exacerbation of chronic obstructive pulmonary disease (COPD) and learns that the client received immunization for pneumococcal pneumonia 6 years ago. Which consideration is essential to include in the plan of care during the client's hospital admission?
- A. Offer revaccination to the client.
- B. Document the previous immunization on the client record.
- C. Instruct the client that this vaccine provides lifelong immunity.
- D. Explain to the client that he can be revaccinated only during the fall months.
Correct Answer: A
Rationale: During the history-taking of a client diagnosed with a respiratory disorder, the nurse should ask if the client had been previously vaccinated for influenza (flu) and had received pneumococcal pneumonia vaccine. Revaccination with pneumococcal pneumonia vaccine is currently advised in a client with COPD if the client received the vaccine more than 5 years previously and if the client was younger than 65 years of age at the time of vaccination. Although documentation would be done, this is not the essential action at this time. This vaccine does not provide lifelong immunity in a 56-year-old client who received the vaccine 6 years ago. The pneumococcal pneumonia vaccine is administered any time during the year.
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The nurse observes a client looking frightened and reporting, 'feeling out of control.' Which therapeutic approach by the nurse is most appropriate to maintain a safe environment?
- A. Administer a PRN antianxiety medication immediately.
- B. Provide isolation for the client in the unit's 'time-out' room.
- C. Observe the client in an ongoing manner but do not intervene.
- D. Encourage the client to talk about her or his feelings in a quiet setting.
Correct Answer: D
Rationale: The anxiety symptoms demonstrated by this client require some form of intervention. Moving the client to a quiet setting decreases environmental stimuli. Talking provides the nurse an opportunity to assess the cause of the client's feelings and identify appropriate interventions. Medication is used only when other noninvasive approaches have been unsuccessful. Isolation is appropriate if a client is a danger to self or others.
The nurse is planning care for a client admitted with suicidal ideations. To best assure client safety the nurse will implement additional precautions during which time period?
- A. During the day shift
- B. On weekday evenings
- C. Between 8 am and 10 am
- D. During the unit shift change
Correct Answer: D
Rationale: At shift change, there is often less availability of staff. The psychiatric nurse and staff should increase precautions for suicidal clients at that time. The night shift also presents a high-risk time, as do weekends, not weekdays.
The nurse is preparing to ambulate a client with a diagnosis of Parkinson's disease who has recently been prescribed levodopa. Which information is most important for the nurse to assess before ambulating the client?
- A. The client's history of falls
- B. Assistive devices used by the client
- C. The client's postural (orthostatic) vital signs
- D. The degree of intention tremors exhibited by the client
Correct Answer: C
Rationale: Clients diagnosed with Parkinson's disease are at risk for postural (orthostatic) hypotension from the disease. This problem is exacerbated with the introduction of levodopa, which can also cause postural hypotension. Although knowledge of the client's risk for falls and the client's use of assistive devices are helpful, it is not the most important piece of assessment data, based on the wording of this question. Clients with Parkinson's disease generally have resting, not intention, tremors.
Which clinical situation should justifiably be viewed as an assault?
- A. The nurse threatens to apply restraints to a client who is exhibiting aggressive behavior.
- B. The client requests a medical discharge, but the nurse physically forces the client to stay.
- C. The charge nurse sends an email to a staff member that includes a poor performance evaluation about another person.
- D. The nurse overhears the primary health care provider making derogatory remarks to the client about the nurse's level of competency.
Correct Answer: A
Rationale: An assault occurs when a person puts another person in fear of a harmful or offensive act. Battery involves offensive touching or the use of force by a perpetrator without the permission of the victim. Defamation takes place when a falsehood is said (slander) or written (libel) about a person that results in injury to that person's good name and reputation.
The nurse should implement which safety measures to prevent an electrical shock when using electrical equipment? Select all that apply.
- A. Use a two-prong outlet.
- B. Check the electrical cord for fraying.
- C. Keep the electrical cord away from the sink.
- D. Place the excess electrical cord under a small carpet.
- E. Grasp the electrical cord when unplugging the equipment.
- F. Disconnect the electrical cord from the wall socket when cleaning the equipment.
Correct Answer: B,C,F
Rationale: The nurse needs to implement measures to prevent an electrical shock when using electrical equipment. These measures include using a three-prong plug that is grounded, checking the electrical cord for fraying or other damage, keeping the electrical cord away from the sink or other sources of water, using electrical tape to secure the excess electrical cord to the floor where it will not be stepped on (the cord should not be placed under carpet), grasping the plug (not the electrical cord) when unplugging the equipment, and disconnecting the electrical cord from the wall socket when cleaning the equipment.