Nokea
The nurse is counseling the family of a terminally ill client about palliative care. The nurse identifies which goals as being those of palliative care? Select all that apply.
- A. The delay of the impending death
- B. Offering a caring support system
- C. Providing measure focused on pain management
- D. Introduction of interventions that enhance the quality of life
- E. Expanding the focus of care to both the client and the family
- F. Addressing the expressed spiritual needs of the client and the family
Correct Answer: B,C,D,E,F
Rationale: Palliative care is a philosophy of total care. Palliative care goals include the following: offering a support system to help the client live as actively as possible until death; providing relief from pain and other distressing symptoms; enhancing the quality of life; offering a support system to help families cope during the client's illness and their own bereavement; affirming life and regarding dying as a normal process, neither hastening nor postponing death; and integrating psychological and spiritual aspects of client care.
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The nurse is preparing to initiate an intravenous nitroglycerin drip on a client who has experienced an acute myocardial infarction. In the absence of an invasive (arterial) monitoring line, the nurse prepares to have which piece of equipment for use at the bedside to help assure the client's safety?
- A. Defibrillator
- B. Pulse oximeter
- C. Central venous pressure (CVP) tray
- D. Noninvasive blood pressure monitor
Correct Answer: D
Rationale: Nitroglycerin dilates arteries and veins (vasodilator), causing peripheral blood pooling, thus reducing preload, afterload, and myocardial workload. This action accounts for the primary side effect of nitroglycerin, which is hypotension. In the absence of an arterial monitoring line, the nurse should have a noninvasive blood pressure monitor for use at the bedside.
The newborn nursery nurse is performing an admission assessment on a newborn with the diagnosis of subdural hematoma. Which intervention should the nurse implement to assess for the primary symptom associated with subdural hematoma?
- A. Monitor the urine for blood.
- B. Monitor the urinary output pattern.
- C. Test for contractures of the extremities.
- D. Test for equality of extremity reflexes.
Correct Answer: D
Rationale: A subdural hematoma can cause pressure on a specific area of the cerebral tissue. This can cause changes in the stimuli responses in the extremities on the opposite side of the body, especially if the newborn is actively bleeding. Options 1 and 2 are incorrect. After delivery, a newborn would normally be incontinent of urine. Blood in the urine would indicate abdominal trauma and would not be a result of the hematoma. Option 3 is incorrect because contractures would not occur this soon after delivery.
The nurse has administered approximately half of a high-cleansing enema when the client reports pain and cramping. Which nursing action is appropriate?
- A. Reassuring the client that those sensations will subside
- B. Discontinuing the enema and notifying the primary health care provider
- C. Raising the enema bag so that the solution can be introduced quickly
- D. Clamping the tubing for 30 seconds and restarting the flow at a slower rate
Correct Answer: D
Rationale: The enema fluid should be administered slowly. If the client complains of pain or cramping, the flow is stopped for 30 seconds and restarted at a slower rate. Slow enema administration and stopping the flow temporarily, if necessary, will decrease the likelihood of intestinal spasm and premature ejection of the solution. The client's report of pain and cramping should not be ignored. The higher the solution container is held above the rectum, the faster the flow and the greater the force in the rectum. There is no need to discontinue the enema and notify the primary health care provider at this time.
The clinic nurse prepares to assess a client who is in the second trimester of pregnancy. When measuring the fundal height, what should the nurse expect to note with this measurement regarding gestational age?
- A. It is less than gestational age.
- B. It correlates with gestational age.
- C. It is greater than gestational age.
- D. It has no correlation with gestational age.
Correct Answer: B
Rationale: Until the third trimester, the measurement of fundal height will, on average, correlate with the gestational age. Therefore, options 1, 3, and 4 are incorrect.
Which questions should the nurse ask when assessing a client for possible manifestations of Ménière's disease? Select all that apply.
- A. Do you experience ringing in your ears?
- B. Are you prone to vertigo that can last for days?
- C. Can you hear better out of one ear than the other?
- D. Is there a history of Ménière's disease in your family?
- E. Have you ever experienced a head injury in the area of your ears?
Correct Answer: A,B,C
Rationale: Ménière's disease is characterized by dilation of the endolymphatic system by overproduction or decreased reabsorption of endolymphatic fluid. Manifestations include tinnitus, vertigo that can last for days, and one-sided sensorineural hearing loss. Although the exact cause of the disease is unknown, there does not seem to be a connection with either genetics or head trauma.