Nokea
The nurse is evaluating how a client who has a halo brace is reacting to this change in his body image. Which statement by the client indicates a need for additional support in adjusting to the brace?
- A. I shall avoid going out in public since I may bump into people.'
- B. I don't mind that people look at me.'
- C. I told my grandchildren that this looks like a space helmet.'
- D. I like to sleep in the reclining chair that we have.'
Correct Answer: A
Rationale: Avoiding public interaction suggests poor adjustment to the halo brace, indicating a need for support to address body image concerns.
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A nurse is performing a dressing change for a hospitalized client with an infected surgical incision. Which actions should the nurse take?
- A. Have the client remove the existing dressing while the nurse prepares sterile supplies
- B. Wear clean gloves for removal and application of a new dressing
- C. Wear clean gloves to remove the existing dressing, changing to sterile gloves to apply the new dressing
- D. Wear sterile gloves, gown, and goggles to remove the soiled existing dressing
Correct Answer: C
Rationale: Clean gloves for removing soiled dressings prevent contamination, while sterile gloves for applying the new dressing maintain a sterile field. Full PPE is excessive for removal, and clean gloves for application risk infection.
The health care provider prescribes paroxetine to a client with depression. What statement by the client indicates proper understanding of the medication?
- A. I can stop taking the medication once my symptoms improve
- B. I must eat a healthy diet and exercise regularly to reduce weight gain
- C. I should feel better within 1 week after starting this medication
- D. I will experience improved sexual performance with this medication
Correct Answer: B
Rationale: Paroxetine may cause weight gain, so a healthy diet and exercise are appropriate. Stopping abruptly risks withdrawal, full effects take weeks, and sexual dysfunction is a common side effect.
A client is being evaluated for carpal tunnel syndrome. The nurse is observed asking the client to place the backs of her hands together and flex them at the same time. Which assessment is the nurse performing?
- A. Phalen's maneuver
- B. Tinel's sign
- C. Kernig's
- D. Brudzinski's
Correct Answer: A
Rationale: Phalen's maneuver involves flexing the wrists with the backs of the hands together to assess for carpal tunnel syndrome, as it may reproduce symptoms. Tinel's sign involves tapping over the median nerve. Kernig's and Brudzinski's are tests for meningitis, not carpal tunnel syndrome.
Laboratory reference ranges
Potassium3.5-5.0 mEq/L(3.5-5.0 mmol/L)
INRNormal: 0.8-1.1Therapeutic: 1.5-4.0
The nurse recognizes which of the following factors as possibly contributing to a sentinel event?
- A. Administered warfarin to a client with an INR of 6.0
- B. Administered flumazenil to a client who overdosed on lorazepam
- C. Initiated nitroprusside infusion in a client with blood pressure of 210/112 mm Hg
- D. Administered insulin/dextrose to a client with potassium level of 7.2 mEq/L (7.2 mmol/L)
Correct Answer: A
Rationale: Administering warfarin with an INR of 6.0 (therapeutic range 2.0-3.0) risks severe bleeding, a sentinel event. Flumazenil is appropriate for lorazepam overdose, nitroprusside for hypertensive crisis, and insulin/dextrose for hyperkalemia are correct interventions.
The nurse is reinforcing discharge instructions for a client with degenerative joint disease and a new prescription for naproxen. What instructions regarding this drug does the nurse include? Select all that apply.
- A. Avoid driving while taking this medicine
- B. Change positions slowly
- C. Discontinue immediately if suicidal thoughts occur
- D. Notify the health care provider of tarry stools
- E. Take the medicine with food
Correct Answer: D,E
Rationale: Tarry stools indicate potential GI bleeding, a serious naproxen side effect, and taking with food reduces GI irritation. Driving, position changes, and suicidal thoughts are not primary concerns with naproxen.