Nokea
The nurse is caring for a client following a cerebral vascular accident. Which portion of the brain is responsible for changes in the client's vision?
- A. Temporal lobe
- B. Frontal lobe
- C. Occipital lobe
- D. Parietal lobe
Correct Answer: C
Rationale: The occipital lobe processes visual information. A cerebral vascular accident affecting this area can cause visual deficits such as hemianopia or visual agnosia. The temporal lobe manages auditory and memory functions, the frontal lobe controls behavior and motor skills, and the parietal lobe handles sensory integration.
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The child with seizure disorder is being treated with phenytoin (Dilantin). Which of the following statements by the patient's mother indicates to the nurse that the patient is experiencing a side effect of Dilantin therapy?
- A. She is very irritable lately.'
- B. She sleeps quite a bit of the time.'
- C. Her gums look too big for her teeth.'
- D. She has gained about 10 pounds in the last six months.'
Correct Answer: C
Rationale: Gingival hyperplasia (overgrown gums) is a common side effect of phenytoin (Dilantin). Irritability, excessive sleep, and weight gain are not typical side effects of this medication.
On the first postpartal day, a client tells the nurse that she has been changing her perineal pads every 1/2 hour because they are saturated with bright red vaginal drainage. When palpating the uterus, the nurse assesses that it is somewhat soft, 1 fingerbreadth above the umbilicus, and midline. The nursing action to be taken is to:
- A. Gently massage the uterus until firm, express any clots, and note the amount and character of lochia
- B. Catheterize the client and reassess the uterus
- C. Begin IV fluids and administer oxytocic medication
- D. Administer analgesics as ordered to relieve discomfort
Correct Answer: A
Rationale: Gentle massage and expression of clots will let the fundus return to a state of firmness, allowing the uterus to function as the 'living ligature.' A distended bladder may promote uterine atony; however, after determining the bladder is distended, the nurse would have the client void. Catheterization is only done if normal bladder function has not returned. Oxytocic medications are ordered and administered if the uterus does not remain contracted after gentle massage and determining if the bladder is empty. The client is not complaining of discomfort or pain; therefore, analgesics are not necessary.
The physician has ordered that ampicillin 250 mg IV be given over 30 minutes. The medication is diluted as recommended in 10 mL in the volume control chamber of a set that has a tubing of 12 mL. Which nursing measure is most accurate considering these facts?
- A. Infuse volume at 44 mL/hr.
- B. Infuse volume at 22 mL/hr.
- C. Infuse volume at 10 mL/hr.
- D. Infuse volume at 30 mL/hr.
Correct Answer: A
Rationale: The volume to be infused should be diluted medication volume added to the volume control chamber (10 mL) plus the tubing volume (12 mL). The general formula for calculating IV medications for children is: Rate = Volume to Be Infused X Administration Set Drop Factor (microdrop: 60 gtts/min) / Desired Time to Infuse in Minutes Rate = (10 + 12) 22 × 60 / 30 = 44 mL/hr. (B, C, D) These values are incorrect.
Which of the following physician's orders would the nurse question on a client with chronic arterial insufficiency?
- A. Neurovascular checks every 2 hours
- B. Elevate legs on pillows
- C. Arteriogram in the morning
- D. No smoking
Correct Answer: B
Rationale: Neurovascular checks are a routine part of assessment with clients having this diagnosis. Elevation of the legs is contraindicated because it reduces blood flow to areas already compromised. Arteriogram is a routine diagnostic order. Smoking is highly correlated with this disorder.
A female client is anticipating a visit with her parents over the Thanksgiving holidays. She has recently begun experiencing periods of extreme shortness of breath, which her physician has labeled as panic attacks. Which of the following statements by the nurse would enhance therapeutic communication?
- A. Why do you feel this way?'
- B. Tell me about your dislike for your parents.'
- C. Don't worry, everything will be all right on your visit with your parents.'
- D. Perhaps you and I can discover what produces your anxiety.'
Correct Answer: D
Rationale: Asking the client to provide an explanation for her feelings is often intimidating. This response is probing and may make the client feel used and valued only for the information she can provide. This underrates the client's feelings and belittles her concerns. It may cause the client to stop sharing feelings for fear that they will be ridiculed. The emphasis is on working with the client. It shows that there is hope for change through collaboration.