Nokea
The nurse is learning about effective nurse leadership. The nurse should recognize that an effective nurse leader has which of the following qualities? SELECT ALL THAT APPLY
- A. Conflict resolution skills
- B. Integrity
- C. Ability to set priorities
- D. Authoritarian leadership style
- E. Resistant to change
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C. A nurse leader needs conflict resolution skills (A) to manage interpersonal issues. Integrity (B) is essential for trust and credibility. The ability to set priorities (C) ensures efficient workflow. Choice D, an authoritarian leadership style, is incorrect as it can hinder teamwork and morale. Choice E, being resistant to change, is incorrect as nurse leaders must adapt to evolving healthcare practices.
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A nurse is providing care to a client with Myasthenia gravis who has lost 6 kg of weight over the past 2 months. What should the nurse suggest to improve this client's nutritional status?
- A. Restrict drinking fluids before and during meals
- B. Plan medication doses to occur before meals
- C. Increase the amount of fat and carbohydrates in meals
- D. Eat three large meals per day
Correct Answer: B
Rationale: The correct answer is B: Plan medication doses to occur before meals. This is because Myasthenia gravis can cause difficulty swallowing, leading to weight loss. Taking medication before meals can enhance the client's ability to eat by improving muscle strength for swallowing and chewing. Restricting fluids (A) may exacerbate swallowing difficulties. Increasing fat and carbohydrates (C) can lead to weight gain but may not address the swallowing issue. Eating three large meals (D) may be challenging for someone with swallowing difficulties.
A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?
- A. Insert a padded tongue blade into the client's mouth
- B. Restrain the client
- C. Move objects away from the client
- D. Place the client on his back
Correct Answer: C
Rationale: The correct answer is C: Move objects away from the client. This instruction is crucial to prevent injury during a seizure by creating a safe environment. Placing objects away from the client reduces the risk of them hitting or injuring themselves. It also allows for a clear space for the client's movements during the seizure.
Choice A is incorrect as inserting a padded tongue blade can cause injury and obstruct the client's airway. Choice B is incorrect as restraining the client can lead to further injury and is not recommended during a seizure. Choice D is incorrect as placing the client on their back can increase the risk of choking or aspiration if they vomit during the seizure.
A nurse is caring for a client receiving rehabilitation for paralysis following a spinal cord injury and diagnosed with reflex incontinence. Which of the following is the highest priority intervention the nurse should include in the plan of care?
- A. Limited fluid intake to prevent incontinence
- B. Administration of antispasmodic medication
- C. Kegel exercises to strengthen the pelvic floor
- D. Regular perineal care to prevent skin breakdown
Correct Answer: D
Rationale: The correct answer is D: Regular perineal care to prevent skin breakdown. This is the highest priority intervention because reflex incontinence can lead to constant urine leakage, increasing the risk of skin breakdown. Regular perineal care helps maintain skin integrity, preventing complications like pressure ulcers. Limited fluid intake (A) is not appropriate as it can lead to dehydration. Antispasmodic medication (B) may help manage muscle spasms but does not address skin breakdown. Kegel exercises (C) are beneficial for stress incontinence, not reflex incontinence.
A nurse is conducting triage of clients transported from a mass casualty incident (MCI). A client arrives saturated with an unknown substance and medical transport reports feeling dizzy. The nurse should prioritize which actions? SELECT ALL THAT APPLY
- A. Assign the client to a private room
- B. Remove client and transport crew from the Emergency department
- C. Contact decontamination team
- D. Call the scene to identify the chemical
- E. Immediately remove the saturated clothing from the client
Correct Answer: B,C,E
Rationale: Correct Answer: B, C, E
Rationale:
1. Option B - Removing the client and transport crew from the Emergency department is crucial to prevent potential contamination of others and ensure safety.
2. Option C - Contacting the decontamination team is essential to properly manage and decontaminate the client and the area.
3. Option E - Removing the saturated clothing from the client immediately helps eliminate further exposure and contamination risks.
Incorrect Answers:
A: Assign the client to a private room - This is not the priority as immediate decontamination and safety measures are needed.
D: Call the scene to identify the chemical - Identifying the substance is important but not the priority when the client's safety is at risk.
A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect?
- A. Gradual onset of headache
- B. Changes in consciousness
- C. Gradual onset of several hours
- D. History of neurologic deficits lasting less than 1 hr
Correct Answer: B
Rationale: The correct answer is B: Changes in consciousness. Following a hemorrhagic stroke from a ruptured cerebral aneurysm, changes in consciousness are expected due to the sudden bleeding into the brain causing increased intracranial pressure. This can lead to symptoms such as confusion, disorientation, stupor, or coma. Choice A is incorrect as a hemorrhagic stroke typically presents with a sudden and severe headache. Choice C is incorrect as the onset of symptoms is usually sudden. Choice D is incorrect as neurologic deficits from hemorrhagic strokes typically last longer than 1 hour.