Nokea
The nurse is caring for a client with a history of a fractured humerus who is in a sling. The client complains of numbness. The nurse should:
- A. Apply ice to the arm
- B. Elevate the arm
- C. Notify the physician immediately
- D. Massage the arm
Correct Answer: C
Rationale: Numbness in a slung humerus suggests neurovascular compromise, requiring immediate physician notification. Ice, elevation, and massage are insufficient or contraindicated.
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Which nursing implication is appropriate for a client undergoing a paracentesis?
- A. Have the client void before the procedure.
- B. Keep the client NPO.
- C. Observe the client for hypertension following the procedure.
- D. Place the client on the right side following the procedure.
Correct Answer: A
Rationale: A full bladder impedes ascitic fluid withdrawal during paracentesis, so the client should void beforehand.
The physician has ordered Eskalith (lithium carbonate) 500 mg three times a day and Risperdal (risperidone) 2 mg twice daily for a client admitted with bipolar disorder, acute manic episodes. The best explanation for the client's medication regimen is:
- A. The client's symptoms of acute mania are typical of undiagnosed schizophrenia.
- B. Antipsychotic medication is used to manage behavioral excitement until mood stabilization occurs.
- C. The client will be more compliant with a medication that allows some feelings of hypomania.
- D. Antipsychotic medication prevents psychotic symptoms commonly associated with the use of mood stabilizers.
Correct Answer: B
Rationale: Risperidone, an antipsychotic, is used to control acute manic symptoms like agitation, while lithium stabilizes mood over time, addressing the immediate behavioral excitement.
A 16-year-old client with anorexia nervosa is on an inpatient psychiatric unit. She has a fear of gaining weight and is refusing to eat sufficient amounts to maintain body weight for her age, height, and stature. To assist with the problem of powerlessness and plan for the client to no longer need to withhold food to feel in control, the nurse uses the following strategy:
- A. Establish a structured environment with routine tasks and activities. Also, serve meals at the same time each day.
- B. Distract the client during meals to get her to eat because she must take in sufficient amounts to keep from starving.
- C. Do frequent room checks to be sure that the client is not hiding food or throwing it away.
- D. Listen attentively and participate in in-depth discussions about food, because these actions may encourage her to eat.
Correct Answer: A
Rationale: Anorexia nervosa clients feel out of control. Providing a structured environment offers safety and comfort and can help them to develop internal control, thus reducing their need to control by self-starvation. Distraction does not focus on the client's need for control. Doing frequent room checks reinforces feelings of powerlessness and the need to continue with the dysfunctional behavior. Participating in long discussions about food does not make the client want to eat, but rather this strategy allows her to indulge in her preoccupation and to continue with the dysfunctional behavior.
Which task should be delegated to the licensed practical nurse?
- A. Administering heparin subcutaneously
- B. Feeding the client with a percutaneous endoscopy gastrostomy tube
- C. Removing a peripherally inserted central line
- D. Monitoring chest tube drainage
- E. Performing tracheostomy care
Correct Answer: A, B, D, E
Rationale: LPNs can administer subcutaneous heparin (A), feed via PEG tube (B), monitor chest tubes (D), and perform tracheostomy care (E). Removing a PICC line (C) requires RN-level expertise due to potential complications.
A 20-year-old female client delivers a stillborn infant. Following the delivery, an appropriate response by the labor nurse to the question, 'Why did this happen to my baby?' is:
- A. It's God's will. It was probably for the best. There was something probably wrong with your baby.'
- B. You're young. You can have other children later.'
- C. I know your other children will be a great comfort to you.'
- D. I can see you're upset. Would you like to see and hold your baby?'
Correct Answer: D
Rationale: The mother and the father require Wsupport; the nurse should not minimize their grief in this situation. Attachment to this infant occurs during the pregnancy for both the mother and father. Another child cannot replace this child. Attachment to this infant occurs during the pregnancy for both the mother and father. Siblings will not replace their feelings or minimize their loss of this infant. Holding and viewing the infant decreases denial and may facilitate the grief process. The nurse should prepare family members for how the infant appears ('she is bruised') and provide support.