Nokea
The nurse is caring for a college football player who recently sustained an accidental, forceful, helmet-to-helmet collision with another running football player. Which sign/symptom is most concerning and alerts the practical nurse to contact the registered nurse immediately?
- A. Continually oozing epistaxis
- B. Halo' across vision
- C. One episode of coffee-ground emesis
- D. Temporal headache
Correct Answer: B
Rationale: A 'halo' across vision (B) suggests a serious neurological issue, such as a concussion or brain injury, requiring immediate attention. Epistaxis (A), emesis (C), and headache (D) are concerning but less urgent unless persistent or worsening.
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The pediatric nurse cares for a 16-year-old client who is scheduled for an appendectomy in the morning. Which of the following interventions are appropriate to support the client's psychosocial needs?
- A. Create a strict daily schedule for the client while hospitalized
- B. Encourage the client to have peers visit while hospitalized
- C. Ensure parental presence during any client procedure
- D. Include the client as an active participant when planning care
- E. Support the client in discussing concerns about body image changes
Correct Answer: B,D,E
Rationale: Peer visits (B), active participation (D), and addressing body image (E) support a teen's psychosocial needs. Strict schedules (A) reduce autonomy, and parental presence (C) may not align with the teen's preferences.
The nurse in a same-day surgery unit assigns the unlicensed assistive personnel (UAP) to provide a hernia patient with a lunch tray. Which statement by the nurse is most appropriate?
- A. Tell the family they can bring in a pizza if the patient would prefer that.
- B. Make sure the patient gets at least 2 cartons of milk
- C. Stop the IV if the patient is able to eat solid food.
- D. Encourage the patient to eat slowly to prevent gas.
Correct Answer: D
Rationale: The professional nurse can delegate tasks with an expected outcome. The UAP is given adequate information about the task and how to promote the best outcome.
An 81-year-old client is admitted to a rehabilitation facility 3 days after total hip replacement. The next morning, the unlicensed assistive personnel (UAP) takes the client's vital signs, but when the UAP returns to assist the client with a shower, the client curses at and tries to hit the UAP. Which is the most appropriate response by the practical nurse?
- A. I will walk to the room to observe the client's behavior.
- B. It sounds like the client is not satisfied with the care provided. I'll see if we can make the client more comfortable.
- C. Just leave the client alone now and try again later.
- D. The client probably has dementia and is under a lot of stress with the change of environment.
Correct Answer: A
Rationale: Observing the client (A) allows assessment of the behavior's cause. Assuming dissatisfaction (B) or dementia (D) is premature. Leaving the client (C) delays intervention.
The nurse supporting a family who has just experienced a sudden and unexpected death needs to know:
- A. that survivors have greater emotional turmoil and shock than when death is expected.
- B. that survivors have less emotional turmoil and shock than when death is expected.
- C. that survivors have the same emotional turmoil and shock as when death is expected.
- D. that survivors have little emotional turmoil and shock because they were not there.
Correct Answer: A
Rationale: Sudden death produces greater emotional turmoil and shock in survivors than does a gradual, expected death.
The nurse is reinforcing education to a client with a venous thromboembolism who is prescribed rivaroxaban. Which statement by the client indicates the medication teaching has been effective?
- A. I need to continue to avoid eating spinach and kale.
- B. I probably will have some weakness in my legs when I take this medicine.
- C. I should avoid taking aspirin while receiving this medication.
- D. I will have to get blood drawn routinely to check my clotting levels.
Correct Answer: C
Rationale: Rivaroxaban is a direct oral anticoagulant that does not require routine monitoring of clotting levels, unlike warfarin. It also does not necessitate dietary restrictions like avoiding spinach and kale, which are relevant for warfarin due to vitamin K interactions. Avoiding aspirin is correct because it increases bleeding risk when combined with rivaroxaban. Weakness in legs is not a typical side effect of rivaroxaban.