Nokea
The nurse is observing care given to a client experiencing severe to panic levels of anxiety. The nurse would intervene in which of the following situations?
- A. The staff maintains a calm manner when interacting with the client.
- B. The staff attends to client's physical needs as necessary.
- C. The staff helps the client identify thoughts or feelings that occurred prior to the onset of the anxiety.
- D. The staff assesses the client's need for medication or seclusion if other interventions have failed to reduce anxiety.
Correct Answer: C
Rationale: in this level of anxiety, client is unable to process thoughts and feelings for problem solving
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The nurse is teaching a client with an orthotopic bladder replacement. The nurse should tell the client to:
- A. Place a gauze pad over the stoma
- B. Lie on her side while evacuating the pouch
- C. Bear down with each voiding
- D. Wear a well-fitting drainage bag
Correct Answer: D
Rationale: A well-fitting drainage bag is essential for managing an orthotopic bladder replacement.
The nurse is caring for a client post-op femoral popliteal bypass graft. Which post-operative assessment finding would require immediate physician notification?
- A. Edema of the extremity and pain at the incision site
- B. A temperature of 99.6°F and redness of the incision
- C. Serous drainage noted at the surgical area
- D. A loss of posterior tibial and dorsalis pedis pulses
Correct Answer: D
Rationale: Loss of distal pulses indicates potential graft occlusion or arterial compromise, a surgical emergency requiring immediate notification.
The nurse is teaching feeding protocol to the spouse of a client who experienced a severe stroke. Which statement by the spouse indicates a need for further explanation by the nurse?
- A. I will not let him use a straw.
- B. I will turn on the television during meals.
- C. Instead of whole pills, I will crush the pill and place it in custard.
- D. He will sit up for a half hour after eating.
Correct Answer: B
Rationale: Turning on the television during meals can distract the client, increasing the risk of aspiration, and requires further teaching. Other statements are appropriate.
The nurse is caring for a client who is disoriented. To avoid using restraints, the nurse chooses alternative methods to help keep the client oriented. Which interventions would the nurse use for this client? Select all that apply.
- A. maintain normal toileting routines
- B. minimize visitation so that the client may rest
- C. evaluate the client's medications for side effects
- D. keep familiar items such as family pictures near the bedside
- E. use calendars and clocks to orient the client to the date and time
- F. place the client in a room near the end of the hall to minimize noise
Correct Answer: A,C,D,E
Rationale: Toileting routines, medication review, familiar items, and calendars/clocks promote orientation. Minimizing visitation may isolate the client, and room placement is less relevant.
The nurse is working in the ED when a client in labor comes in and says that she does not have health insurance, but wants to know if a doctor will see her. The nurse understands that the client's right to emergency services, regardless of ability to pay, is provided by which piece of legislation?
- A. HIPAA
- B. the Continuity of Care Act
- C. the Patient's Bill of Rights
- D. the Code of Ethics for Nurses
Correct Answer: D
Rationale: The Emergency Medical Treatment and Active Labor Act (EMTALA) ensures that emergency services are provided regardless of ability to pay, not the options listed.