Nokea
The nurse is evaluating the evidence-based practice used for the units' client care standards. Which of the following provides the most support for evidence-based practice?
- A. Client preference
- B. Practice guidelines
- C. Care plans
- D. Research journal articles
- E. Systematic literature reviews
Correct Answer: B, D, E
Rationale: Evidence-based practice relies on practice guidelines (B), research articles (D), and systematic reviews (E) for high-quality evidence. Client preference (A) and care plans (C) are individualized but less rigorous.
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Prior to administering digoxin to a client with congestive heart failure, the nurse needs to assess:
- A. Respiratory rate for 1 minute
- B. Radial pulse for 1 minute
- C. Radial pulse for 2 minutes
- D. Apical pulse for 1 minute
Correct Answer: D
Rationale: Apical pulse should be measured for 1-minute prior to digoxin administration. Digoxin decreases the heart rate. Digoxin should be withheld if apical rates are <60 bpm or >120 bpm.
The physician has ordered Eskalith (lithium carbonate) 500 mg three times a day and Risperdal (risperidone) 2 mg twice daily for a client admitted with bipolar disorder, acute manic episodes. The best explanation for the client's medication regimen is:
- A. The client's symptoms of acute mania are typical of undiagnosed schizophrenia.
- B. Antipsychotic medication is used to manage behavioral excitement until mood stabilization occurs.
- C. The client will be more compliant with a medication that allows some feelings of hypomania.
- D. Antipsychotic medication prevents psychotic symptoms commonly associated with the use of mood stabilizers.
Correct Answer: B
Rationale: Risperidone, an antipsychotic, is used to control acute manic symptoms like agitation, while lithium stabilizes mood over time, addressing the immediate behavioral excitement.
The nurse is teaching a client with a history of migraines about trigger avoidance. The nurse should tell the client to avoid:
- A. Chocolate
- B. Fresh vegetables
- C. Lean meats
- D. Whole grains
Correct Answer: A
Rationale: Chocolate is a common migraine trigger, potentially causing vasoconstriction or neurotransmitter changes, so it should be avoided.
The mother of a six-year-old with autistic disorder tells the nurse that her son has been much more difficult to care for since the birth of his sister. The best explanation for changes in the child's behavior is:
- A. The child did not want a sibling.
- B. The child was not adequately prepared for the baby's arrival.
- C. The child's daily routine has been upset by the birth of his sister.
- D. The child is just trying to get the parent's attention.
Correct Answer: C
Rationale: Children with autism often rely on structured routines, and disruptions, such as a new sibling, can lead to behavioral changes due to difficulty adapting to change.
An obstetrical client is admitted in active labor. During examination,the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
- A. Document the finding
- B. Report the finding to the physician
- C. Prepare the client for a C-section
- D. Continue primary care as prescribed
Correct Answer: B
Rationale: A papular lesion on the perineum during labor could indicate an infectious condition (e.g. herpes simplex virus) which poses risks to the newborn. Reporting to the physician is the most appropriate initial action to determine management such as the need for a C-section.