Nokea
The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, the nurse's documentation should include which of the following? Select all that apply.
- A. Nutrition and hydration needs.
- B. Circulation and skin integrity.
- C. Range of motion and positioning.
- D. Behavioral responses and mental status.
Correct Answer: A,B,C,D
Rationale: Documentation must include nutrition/hydration, circulation/skin integrity, range of motion/positioning, and behavioral/mental status to ensure safety and compliance.
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A client with cirrhosis is receiving Lactulose (Cephulac). During the assessment the nurse notes increased confusion and asterixis. The nurse should:
- A. Assess for GI bleeding.
- B. Hold the Lactulose (Cephulac).
- C. Increase protein in the diet.
- D. Monitor serum bilirubin levels.
Correct Answer: A
Rationale: Confusion and asterixis indicate hepatic encephalopathy, often precipitated by GI bleeding (A), which increases ammonia levels. Holding lactulose (B) is incorrect as it reduces ammonia. Increasing protein (C) worsens encephalopathy. Bilirubin (D) is unrelated to acute symptoms.
The nurse learns that a client who is scheduled for a tonsillectomy has been taking 40 mg of oral prednisone daily for the last week for poison ivy on his leg. What is the nurse's best action?
- A. Document the prednisone with current medications.
- B. Notify the surgeon of the poison ivy.
- C. Notify the anesthesiologist of the prednisone administration.
- D. Send the client to surgery.
Correct Answer: C
Rationale: Prednisone use affects adrenal function and stress response, increasing risks during anesthesia. Notifying the anesthesiologist ensures proper perioperative management, such as stress-dose steroids.
A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than age 20?
- A. Head trauma.
- B. Electrolyte imbalance.
- C. Congenital defect.
- D. Epilepsy.
Correct Answer: A
Rationale: Head trauma is a primary cause of seizures in adults over 20, especially in the context of a recent injury. Electrolyte imbalances, congenital defects, or epilepsy are less likely without additional history.
The following scenario applies to the next 1 items
The nurse in the emergency department (ED) is performing discharge education for a 31-year-old female client.
Item 1 of 1
Progress Notes Orders
1710: The client has pelvic inflammatory disease and bacterial vaginosis. Will discharge the client home with antibiotics and with the instruction that the client should follow-up with her primary physician in two weeks.
The nurse is teaching a client about their prescribed medications. For each education statement, click to specify if the statement is relevant to metronidazole or doxycycline.
- A. You will need to use a backup method of contraception.
- B. Avoid consuming and using products with alcohol.
- C. You may experience a darkening of your urine.
- D. Do not take this medication with food or drinks containing calcium.
Correct Answer: A,B,C,D
Rationale: A (Doxycycline): Doxycycline can reduce the effectiveness of hormonal contraceptives, requiring a backup method. B (Metronidazole): Alcohol should be avoided with metronidazole due to a disulfiram-like reaction. C (Metronidazole): Darkening of urine is a side effect of metronidazole. D (Doxycycline): Calcium-containing foods/drinks reduce doxycycline absorption.
When teaching a client with chronic obstructive pulmonary disease to conserve energy, the nurse should teach the client to lift the patient.
- A. While inhaling through an open mouth.
- B. While exhaling through pursed lips.
- C. After exhaling but before inhaling.
- D. While taking a deep breath and holding it.
Correct Answer: B
Rationale: Lifting while exhaling through pursed lips conserves energy by aligning effort with prolonged exhalation, reducing air trapping in COPD. Other methods increase respiratory workload.