Nokea
The nurse is assessing the casted extremity of a client for signs of infection. Which finding is indicative of the presence of an infection?
- A. Dependent edema
- B. Diminished distal pulse
- C. Coolness and pallor of the skin
- D. Presence of warm areas on the cast
Correct Answer: D
Rationale: Manifestations of infection under a casted area include a musty odor or purulent drainage from the cast or the presence of areas on the cast that are warmer than others. The primary health care provider should be notified if any of these occur. Dependent edema, diminished arterial pulse, and coolness and pallor of the skin all signify impaired circulation in the distal extremity.
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The nurse is preparing to administer a tuberculin skin test to a client. The nurse determines that which area is to be used for injection of the medication?
- A. Dorsal aspect of the upper arm near a mole
- B. Inner aspect of the forearm that is close to a burn scar
- C. Inner aspect of the forearm that is not heavily pigmented
- D. Dorsal aspect of the upper arm that has a small amount of hair
Correct Answer: C
Rationale: Intradermal injections are most commonly given in the inner surface of the forearm. Other sites include the dorsal area of the upper arm or the upper back beneath the scapulae. The nurse finds an area that is not heavily pigmented and is clear of hairy areas or lesions that could interfere with reading the results.
A client experiencing trigeminal neuralgia (tic douloureux) asks the nurse for a snack and something to drink. Which is the best selection the nurse should provide for the client?
- A. Hot cocoa with honey and toast
- B. Vanilla pudding and lukewarm milk
- C. Hot herbal tea with graham crackers
- D. Iced coffee and peanut butter and crackers
Correct Answer: B
Rationale: Because mild tactile stimulation of the face of clients with trigeminal neuralgia can trigger pain, the client needs to eat or drink lukewarm, nutritious foods that are soft and easy to chew. Extremes of temperature will cause trigeminal pain.
The nurse notes an isolated premature ventricular contraction (PVC) on the cardiac monitor of a client recovering from anesthesia. Which action should the nurse take?
- A. Prepare for defibrillation.
- B. Continue to monitor the rhythm.
- C. Prepare to administer lidocaine hydrochloride.
- D. Notify the primary health care provider immediately.
Correct Answer: B
Rationale: As an isolated occurrence, the PVC is not life-threatening. In this situation, the nurse should continue to monitor the client. Frequent PVCs, however, may be precursors of more life-threatening rhythms, such as ventricular tachycardia and ventricular fibrillation. If this occurs, the primary health care provider needs to be notified. Defibrillation is done to treat ventricular fibrillation. Lidocaine hydrochloride is not needed to treat isolated PVCs; it may be used to treat frequent PVCs in a client who is symptomatic and is experiencing decreased cardiac output.
Which interventions should the emergency department nurse prepare for in the care of a child with croup and epiglottitis? Select all that apply.
- A. Obtaining a chest x-ray
- B. Obtaining a throat culture
- C. Monitoring pulse oximetry
- D. Maintaining a patent airway
- E. Providing humidified oxygen
- F. Administering antipyretics and antibiotics
Correct Answer: A,C,D,E,F
Rationale: Epiglottitis is an acute inflammation and swelling of the epiglottis and surrounding tissue. It is a life-threatening, rapidly progressive condition that may cause complete airway obstruction within a few hours of onset. The most reliable diagnostic sign is an edematous, cherry-red epiglottis. Some interventions include obtaining a chest x-ray film, monitoring pulse oximetry, maintaining a patent airway, providing humidified oxygen, and administering antipyretics and antibiotics. The child may also require intubation and mechanical ventilation. The primary concern in a child with epiglottitis is the development of complete airway obstruction. Therefore, the child's throat is not examined or cultured because any stimulation with a tongue depressor or culture swab could trigger complete airway obstruction.
The nurse in the mental health unit is preparing to admit a severely depressed client. Which findings on assessment support the diagnosis of this client? Select all that apply.
- A. Insomnia
- B. Flat affect
- C. Hypersomnia
- D. Substantial weight loss
- E. Weight gain since onset of depression
- F. Reports, 'I don't have any more tears to cry.'
Correct Answer: A,B,D,F
Rationale: In the severely depressed client, loss of weight is typical, whereas the mildly depressed client may experience a gain in weight. Sleep is generally affected in a similar way, with hypersomnia in the mildly depressed client and insomnia in the severely depressed client. The severely depressed client may report that no tears are left for crying. A flat affect may be associated with depression.