Nokea
The nurse is caring for a client with bipolar disorder who is hospitalized for an acute manic episode. Which of the following actions would the nurse expect to be included in the client's plan of care? Select all that apply.
- A. Ask the client to plan an outing for the unit
- B. Assign the client to a private room
- C. Assist client in choosing appropriate clothing
- D. Include the client in group therapy sessions
- E. Schedule the client for physical activity with a staff member
- F. Seat the client with other clients in the dining room for meals
Correct Answer: B,C,D,E,F
Rationale: During a manic episode, a private room (B) minimizes stimuli, appropriate clothing (C) supports dignity, group therapy (D) fosters socialization, physical activity (E) channels energy, and dining with others (F) promotes normalcy. Planning an outing (A) is inappropriate due to impulsivity risks.
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To maintain Bryant's traction, the nurse must make certain that the child's:
- A. Hips are resting on the bed with the legs suspended at a right angle to the bed
- B. Hips are slightly elevated above the bed with the legs suspended at a right angle to the bed
- C. Hips are elevated above the level of the body on a pillow with the legs suspended parallel to the bed
- D. Hips and legs are flat on the bed with the traction positioned at the foot of the bed
Correct Answer: B
Rationale: Bryant's traction requires hips slightly elevated and legs at a right angle to the bed to align the femur properly and reduce pressure on the pelvis.
A young adult is admitted with a possible head injury. The car in which he was riding hit a utility pole, and the client's head hit the windshield. Baseline vital signs are BP=112/74, P=80, and R=12. The nurse checks the client an hour after admission. Which finding(s) are significant and should be reported to the charge nurse or physician immediately? Select all that apply.
- A. BP=126/68
- B. Pulse=62
- C. Respirations=8
- D. Projectile vomiting
- E. Client's skin is cool to the touch.
- F. Both pupils respond to exposure to flashlight by constricting.
Correct Answer: C,D
Rationale: Slow respirations (8) and projectile vomiting suggest increased intracranial pressure, critical in head injury, requiring immediate reporting. BP, pulse, skin, and pupil response changes are less urgent.
The nurse is preparing a client for a magnetic resonance cholangiopancreatography. Which statements by the client would require the nurse to obtain further assessment data? Select all that apply.
- A. I ate lunch about 4 or 5 hours ago.
- B. I got a rash the last time I had IV contrast.
- C. I had my last period 6 weeks ago.
- D. I have a hearing aid implanted in my ear.
- E. I smoked a cigarette about an hour ago.
Correct Answer: B,C,D
Rationale: A contrast allergy rash (B) requires premedication or alternative imaging. A possible pregnancy (C) needs confirmation due to MRI risks. A hearing aid implant (D) may be MRI-incompatible. Recent eating (A) is less critical unless sedation is planned, and smoking (E) is irrelevant.
A 2-year old is hospitalized with gastroenteritis and dehydration. Which of the following methods is best for evaluating changes in skin turgor?
- A. Pinching the abdominal tissue while the client is supine
- B. Pinching the tissue of the forearm while the client is sitting
- C. Pressing the skin of the lower extremities while the client is supine
- D. Pinching the skin of the lower extremities while the client is sitting
Correct Answer: A
Rationale: Pinching abdominal tissue while supine is the best method to assess skin turgor in a dehydrated child, as it reflects hydration status accurately.
Laboratory results
WBC
5000-10,000/mm³
(5-10 × 10⁹/L) 1400/mm3
(1.4 × 109/L)
Hemoglobin
Male: 14-18 g/dL
(140-180 g/L)
Female: 12-16 g/dL
(120-160 g/L) 10 g/dL
(100 g/L)
Absolute neutrophil count
2500-8000/mm³
(2.5-8 × 10⁹/L) 500/mm3
(0.5 × 109/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 3.4 mEq/L
(3.4 mmol/L)
Platelets
150,000-400,000/mm³
(150-400 × 10⁹/L) 150,000/mm3
(150 × 109/L)
A client in the hospital is receiving chemotherapy. Based on today’s blood laboratory results, which of the following actions should the nurse take?
- A. Check for hematuria
- B. Check for peaked T waves
- C. Obtain prescription for epoetin alfa
- D. Place a face mask on the client
Correct Answer: D
Rationale: Chemotherapy often causes neutropenia, increasing infection risk. A face mask (D) protects the client. Hematuria (A), peaked T waves (B), and epoetin (C) address other issues not directly indicated.