Nokea
The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize the client is at greater risk for the development of which complication?
- A. Hypothyroidism.
- B. Hypertension.
- C. Peptic ulcer disease.
- D. Fibromyalgia.
Correct Answer: B
Rationale: Sleep apnea increases hypertension risk due to oxygen desaturation.
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History and physical
The client is a 28-year-old male who was admitted to the hospital for seizure medication adjustment. Has been having breakthrough seizures over the past month. Has a neurological disorder causing spasticity and limited ability to speak. Currently, has pain in the right leg of unexplained origin.
Nurses Notes
Administered seizure medication. Moved from chair to bed. Made a sound like moaning. Withdrew right leg from touch. Attempted to place leg in position of comfort but experienced muscle spasm. Facial grimacing
Flowsheet
Heart rate 102 beats/minute
The nurse is planning care for the client.Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
- A. Assign a sitter to stay with the client;Have family stay at the bedside;Request antispasmodic medication;Request prescription for pain medication;Use objective symptoms to assess pain
- B. Chronic pain;Visceral pain;Referred pain;Acute pain
- C. Vital signs;Decrease in seizures;Response to pain medications;Joint mobility;Severity of muscle spasms
Correct Answer:
Rationale: Acute pain: The client’s symptoms, such as moaning, facial grimacing, and muscle spasms in the right leg, suggest they are experiencing acute pain. This condition is consistent with the sudden onset of pain and physical reactions.
Request prescription for pain medication: This action addresses the client’s immediate pain needs, helping to alleviate discomfort and improve overall well-being.
Request antispasmodic medication: The muscle spasms observed indicate that an antispasmodic may help reduce the muscle tension and associated pain, providing relief from the spasms.
Response to pain medications: Monitoring the client's response to the prescribed pain medication will help determine the effectiveness of the intervention and whether further adjustments are needed.
Severity of muscle spasms: Assessing the severity of muscle spasms will help evaluate the impact of the antispasmodic treatment and provide insight into the client’s progress in managing the pain.
The mother of a child born with Tetralogy of Fallot asks the nurse, 'Why did this happen to my baby? What did I do wrong?' Which response by the nurse is most helpful?
- A. This must be a very difficult time for you.'
- B. You did nothing wrong.'
- C. With surgery, your baby should have a full recovery.'
- D. Is there any particular reason why you think this is your fault?'
Correct Answer: A
Rationale: Empathy supports emotional expression without judgment.
Which assessment is most important for the nurse to perform prior to the application of a heating pad?
- A. Muscle strength and tone.
- B. Presence of rebound phenomenon.
- C. Limitations to range of motion.
- D. Degree of neurosensory impairment.
Correct Answer: D
Rationale: Neurosensory impairment risks burns.
The healthcare provider gives a verbal prescription for 2 mg of intravenous morphine to be given to a client every 4 hours as needed for severe pain. How should the nurse document the prescription?
- A. Morphine 2.0 mg IV every four hours for severe pain.
- B. Morphine 2 mg IV every 4 hr PRN for severe pain.
- C. IV MS 2 mg every 4 hr as needed for severe pain.
- D. IV MS 2.0 mg every 4 hours PRN for severe pain.
Correct Answer: B
Rationale: Full drug name and no trailing zeros ensure clarity.
While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?
- A. Notify the information services department of the situation.
- B. Print electronic medical record (EMR) from the backup server.
- C. Identify information as a late entry in the record.
- D. Wait for notification that the system has been rebooted.
Correct Answer: A
Rationale: Notifying IT ensures prompt system resolution.