Nokea
The nurse is caring for a client with dementia who tends to wander. Which of the following actions can help with this behavior? Select all that apply.
- A. providing frequent toileting or incontinence care as needed
- B. assessing client for pain and treat with appropriate medications
- C. reorienting the client and use validation therapy, as appropriate
- D. allowing the client to sit in a recliner at the nurses' station for close monitoring
- E. using chemical or physical restraints to prevent the client from exiting the bed
Correct Answer: A, B, C, D
Rationale: Frequent toileting, pain management, reorientation, and close monitoring address wandering causes and promote safety. Restraints are a last resort and not ideal for wandering.
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The nurse is caring for a client following the removal of a central line catheter when the client suddenly develops dyspnea and complains of substernal chest pain. The client is noticeably confused and fearful. Based on the client's symptoms, the nurse should suspect which complication of central line use?
- A. Myocardial infarction
- B. Air embolus
- C. Intrathoracic bleeding
- D. Vagal response
Correct Answer: B
Rationale: Sudden dyspnea, chest pain, and confusion post-central line removal suggest an air embolus, a serious complication requiring immediate intervention.
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 is a common side effect of phenytoin therapy.
A client is 2 days post-operative colon resection. After a coughing episode, the client's wound eviscerates. Which nursing action is most appropriate?
- A. Reinsert the protruding organ and cover with 4x4s
- B. Cover the wound with a sterile 4x4 and ABD dressing
- C. Cover the wound with a sterile saline-soaked dressing
- D. Apply an abdominal binder and manual pressure to the wound
Correct Answer: C
Rationale: Covering the eviscerated wound with a sterile saline-soaked dressing keeps the protruding organs moist and prevents infection until surgical repair.
A mother asks the home health nurse for guidance on what foods are safe to give her child, who is on strict neutropenic precautions. The nurse looks at the mother's grocery list and advises her to avoid
- A. canned peaches.
- B. pasteurized whole milk.
- C. the fresh veggie tray.
- D. fresh bananas.
Correct Answer: C
Rationale: Neutropenic precautions require avoiding fresh, unprocessed foods (e.g., fresh veggies) due to bacterial risk. Canned, pasteurized, or peeled foods are safer.
The home health nurse is visiting an 18-year-old with osteogenesis imperfecta. Which information obtained on the visit would cause the most concern? The client:
- A. Likes to play football
- B. Drinks carbonated drinks
- C. Has two sisters
- D. Is taking acetaminophen for pain
Correct Answer: A
Rationale: Playing football poses a high risk of fractures in osteogenesis imperfecta due to brittle bones, causing significant concern.