Nokea
The nurse is caring for a client with a cerebrovascular accident (CVA) who is complaining of being nauseated and is requesting an emesis basin. Which action would the nurse take first?
- A. Administer an ordered antiemetic.
- B. Obtain an ice bag and apply to the client's throat.
- C. Turn the client to one side.
- D. Notify the physician.
Correct Answer: C
Rationale: Turning the client to one side prevents aspiration, a priority in a nauseated CVA client with potential swallowing deficits. Administering an antiemetic (A) or notifying the physician (D) is secondary, and ice (B) is ineffective.
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Which of the following menu choices would indicate that a client with pressure ulcers understands the role diet plays in restoring her albumin levels?
- A. Broiled fish with rice
- B. Bran flakes with fresh peaches
- C. Lasagna with garlic bread
- D. Cauliflower and lettuce salad
Correct Answer: A
Rationale: Broiled fish and rice are excellent protein sources, aiding in restoring albumin levels for tissue repair. The other options are lower in protein.
A mother frantically calls the emergency room (ER) asking what to do about her 3-year-old girl who was found eating pills out of a bottle in the medicine cabinet. The ER nurse tells the mother to:
- A. Give the child 15 mL of syrup of ipecac.
- B. Give the child 10 mL of syrup of ipecac with a sip of water.
- C. Give the child 1 cup of water to induce vomiting.
- D. Bring the child to the ER immediately.
Correct Answer: D
Rationale: Before giving any emetic, the substance ingested must be known. At least 8 oz of water should be administered along with ipecac syrup to increase volume in the stomach and facilitate vomiting. Water alone will not induce vomiting. An emetic is necessary to facilitate vomiting. Vomiting should never be induced in an unconscious client because of the risk of aspiration.
A 4-year-old child with a history of sickle cell anemia is admitted to the nursing unit with dizziness, shortness of breath, and pallor. Nursing assessment findings reveal tenderness in the abdomen. The child is most likely experiencing a/an:
- A. Aplastic crisis
- B. Vaso-occlusive crisis
- C. Dactylitis crisis
- D. Sequestration crisis
Correct Answer: D
Rationale: Aplastic anemia is characterized by a lack of reticulocytes in the blood. Platelet and white blood cell counts are usually not depressed. It is usually self-limiting, lasting 5-10 days. Vaso-occlusive crisis is the most common type of crisis in sickle cell anemia. Sickled cells become clogged, leading to distal tissue hypoxia and infarction. Joints and extremities are the most commonly affected areas. Dactylitis crisis, or 'hand-foot syndrome,' causes symmetrical infarction of the bones in the hands and feet, resulting in painful swelling in the soft tissues of the hands and feet. Sequestration crisis occurs as enormous volumes of blood pool within the spleen. The spleen enlarges, causing tenderness. Signs of shock including pallor, tachypnea, and faintness result, related to the deficient intravascular volume. This type of crisis is potentially fatal.
A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:
- A. I understand that the voices are real to you, but I want you to know I don't hear them. They are a symptom of your illness.'
- B. Just don't pay attention to the voices. They'll go away after some medication.'
- C. You can't leave here. This unit is locked and the doctor has not ordered your discharge.'
- D. We will have to put you in seclusion and restraints for a while. You could hurt someone with thoughts like that.'
Correct Answer: A
Rationale: This response validates the client's experience and presents reality to him. This nontherapeutic response minimizes and dismisses the client's verbalized experience. This response can be interpreted by a paranoid client as a threat, thereby increasing the client's potential for violence and loss of control. This response is also threatening. The client's behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion or restraints were indicated, the nurse should never confront the client alone.
After several days, an IDDM client's serum glucose stabilizes, and the registered nurse continues client teaching in preparation for his discharge. The nurse helps him plan an American Diabetes Association diet and explains how foods can be substituted on the exchange list. He can substitute 1 oz of poultry for:
- A. One frankfurter
- B. One ounce of ham
- C. Two slices of bacon
- D. One-fourth cup dry cottage cheese
Correct Answer: D
Rationale: Diabetic meat-exchange lists are categorized into lean-meat foods, medium-fat meats, and high-fat meats. Cottage cheese (dry, 2% butterfat), one-fourth cup, can substitute for one lean-meat exchange.