Nokea
The nurse is caring for a client with Rheumatoid Arthritis. Which nursing diagnosis should receive priority in the plan of care?
- A. Risk for injury
- B. Self care deficit
- C. Alteration in comfort
- D. Alteration in mobility
Correct Answer: C
Rationale: Alteration in comfort. Relieving pain is the number one objective of this client's plan of care.
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The nurse is preparing to care for a client who has returned to the surgical nursing unit following a radical neck dissection.
- A. What is the most appropriate nursing action for a client post-radical neck dissection with a tracheostomy?
- B. Suction the tracheostomy every four hours.
- C. Provide tracheostomy care every 12 hours.
- D. Assess the tracheostomy for patency every shift.
- E. Monitor the tracheostomy site for bleeding or swelling.
Correct Answer: D
Rationale: Following a radical neck dissection, monitoring the tracheostomy site for bleeding or swelling is critical due to the risk of hematoma or airway obstruction, which can be life-threatening. Suctioning and care are important but follow a schedule or as needed, and patency assessment is less urgent than monitoring for surgical complications.
A client is admitted to the emergency room in severe emotional distress. The client's respirations are 42/min, and the blood gases reveal a pH of 7.5 and a PaCO2 of 34.
Initially the nurse should
- A. instruct the client to breathe into a paper bag.
- B. start an IV of D5W.
- C. administer O2.
- D. have the client place his head between his knees.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-because of hyperventilation, client is in alkalosis; having him rebreathe his own carbon dioxide will reverse his blood gas imbalance (2) does not address the problem (3) is not hypoxic (4) is done when a client feels faint
An adult is hospitalized for heart failure. Hydrochlorothiazide and digoxin are prescribed. What laboratory test(s) should the nurse monitor because the client is taking these medications?
- A. CBC and differential
- B. Serum creatinine and BUN
- C. Cardiac enzymes
- D. Serum electrolytes
Correct Answer: D
Rationale: Hydrochlorothiazide and digoxin can cause electrolyte imbalances (e.g., hypokalemia), increasing digoxin toxicity risk, necessitating serum electrolyte monitoring.
A client with stage-four Parkinson's disease.
In developing discharge plans with the family of the client with stage-four Parkinson's disease, it is MOST important for the nurse to include which of the following activities?
- A. Ambulate twice daily.
- B. ROM exercise to all extremities four times a day.
- C. Include activities such as knitting and putting puzzles together.
- D. Encourage and provide writing materials.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client would be unable to ambulate (2) correct-in stage four Parkinson's disease, client is immobile (3) client cannot perform activities that require small-muscle dexterity (4) client cannot perform activities that require small-muscle dexterity
The nurse is caring for a client who is suffering from severe anxiety. What must the client do first when learning to deal with his anxiety?
- A. Recognize that he is feeling anxious
- B. Identify the situations that precipitated his anxiety
- C. Understand the reason for his anxiety
- D. Select a strategy to use to help him cope with his anxiety
Correct Answer: A
Rationale: Recognizing anxiety is the first step in managing it, enabling the client to address triggers, reasons, and coping strategies sequentially.