Nokea
The nurse is caring for assigned clients. Which of the following clients would be appropriate for the nurse to refer for an interdisciplinary conference? A client with Select all that apply.
- A. pulmonary tuberculosis with multiple prescriptions.
- B. ischemic stroke who has left-sided hemiplegia.
- C. hyperthyroidism and is scheduled for a thyroidectomy.
- D. stage one Alzheimer’s disease who lives with family.
- E. fractured tibia and fibula and is homeless.
- F. end-stage-renal disease who refuses dialysis.
Correct Answer: A, B, E, F
Rationale: TB with multiple drugs (A), stroke with hemiplegia (B), homeless with fractures (E), and dialysis refusal (F) require interdisciplinary coordination due to complex medical, social, or ethical needs. Thyroidectomy (C) and early Alzheimer’s (D) are less complex for conferencing.
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You are caring for a group of psychiatric mental health clients. One of these clients, who has anger management and aggressive behavior concerns, has not yet gained telephone privileges. You notice an unlicensed assistive personnel (UAP) on the unit escorting this client to the telephone. After you speak to the client about the telephone privileges, the UAP tells you, 'It is unfair for this client not to be able to use the telephone when other clients are free to do so.' What should you determine about this UAP’s comment?
- A. This comment demonstrates that the unlicensed assistive personnel (UAP) favors this client.
- B. This comment indicates that the unlicensed assistive personnel (UAP) is ensuring equal rights.
- C. This comment indicates that the unlicensed assistive personnel (UAP) is preventing discrimination.
- D. This comment indicates a learning need for the unlicensed assistive personnel (UAP) relating to the therapeutic milieu.
Correct Answer: D
Rationale: The UAP’s comment (D) reflects a lack of understanding of the therapeutic milieu, where restrictions like telephone privileges are part of a care plan to manage aggression. It does not indicate favoritism (A), equal rights (B), or anti-discrimination (C), but a need for education on unit protocols.
The nurse is caring for a client receiving a prescribed diltiazem infusion. The client has the following tracing on the electrocardiogram shown in the exhibit. The nurse should perform which priority action? See the exhibit for additional client information.
- A. pause the diltiazem infusion.
- B. notify the primary healthcare physician (PHCP).
- C. assess the client's oxygen saturation and respiratory rate (RR).
- D. prepare a prescription of intravenous (IV) atropine
Correct Answer: A
Rationale: The tracing shows sinus bradycardia. The priority action would be to pause the diltiazem infusion, as this medication is a calcium channel blocker that lowers heart rate and blood pressure. If the infusion continued, it would lower the heart rate to dangerous levels, compromising cardiac output. Once paused, the nurse should contact the primary healthcare provider.
The nurse and unlicensed assistive personnel (UAP) are caring for assigned clients. Which of the following tasks would be appropriate for the nurse to assign to UAP?
- A. Providing oral care for an unconscious client with a tracheostomy
- B. Assisting a client with diabetes in monitoring blood glucose levels
- C. Assisting a client with a history of falls with ambulation in the hallway
- D. Assisting a client with wound dressing changes for a surgical incision
Correct Answer: C
Rationale: Assisting with ambulation for a client with fall risk (C) is within the UAP’s scope, ensuring safety with supervision. Oral care for tracheostomy (A), glucose monitoring (B), and dressing changes (D) require clinical judgment or sterility, inappropriate for UAPs.
The nurse is caring for a client diagnosed with multiple myeloma. The nurse reviews the client's lab values and notes a serum calcium level of 14 mg/dL (3.5 mmol/L) [9-10.5 mg/dL]. What is the priority action the nurse should take?
- A. Notify the primary healthcare provider (PHCP)
- B. Document the finding
- C. Continue to monitor the client
- D. Remove the client from the telemetry monitor
Correct Answer: A
Rationale: Hypercalcemia of 14 mg/dL in multiple myeloma (A) is a medical emergency risking cardiac arrhythmias, requiring immediate PHCP notification. Documentation (B) and monitoring (C) are secondary, and removing telemetry (D) is inappropriate, as monitoring is needed.
The nurse is caring for assigned clients. The nurse should first assess the client
- A. with pericarditis who reports increasing chest pain while laying down flat.
- B. with cystic fibrosis who has a temperature of 102.5°F (39.2°C).
- C. who has rhinosinusitis and is reporting facial pain that increases when bending forward.
- D. who has hypertrophic cardiomyopathy and has dyspnea after ambulating in the hallway.
Correct Answer: A
Rationale: Increasing chest pain when lying flat in pericarditis (A) suggests worsening pericardial effusion, a life-threatening condition requiring immediate assessment. Fever in cystic fibrosis (B), sinusitis pain (C), and dyspnea in cardiomyopathy (D) are less urgent.