Nokea
The nurse is performing a baseline assessment of a client's skin integrity. Which of the following is a key assessment parameter?
- A. Family history of pressure ulcers
- B. Presence of existing pressure ulcers
- C. Potential areas of pressure ulcer development
- D. Overall risk of developing pressure ulcers
Correct Answer: D
Rationale: When assessing skin integrity, the overall risk potential for developing pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers as well as potential areas for development of pressure ulcers. Family history isn't important when assessing skin integrity.
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The nurse is caring for a client who had knee surgery this morning. Postoperative orders include a narcotic every three to four hours as needed for operative site pain and an ice bag. At 7:00 P.M., the client asks for pain medication. He was last medicated at 3:30 P.M. What is the best initial nursing action?
- A. Administer the prescribed analgesic
- B. Assess the location and nature of the pain
- C. Refill the ice bag as needed
- D. Reposition the client
Correct Answer: B
Rationale: Assessing pain location and nature ensures the medication is appropriate for operative site pain, guiding safe administration. Administering without assessment, refilling ice, or repositioning are premature.
Prochlorperazine maleate (Compazine) 10 mg IM has been ordered for a client. The client is also to receive Stadol 2 mg IM. Before administering these medications, the nurse should
- A. obtain respirations and temperature.
- B. dilute with 9 ml of NS.
- C. draw the medications in separate syringes.
- D. verify the route of administration.
Correct Answer: C
Rationale: Compazine (prochlorperazine) is incompatible with most medications, including Stadol (butorphanol), in the same syringe, as mixing may cause precipitation or reduced efficacy. Drawing them in separate syringes ensures safe administration. Monitoring vital signs (A) is less critical, dilution (B) is inappropriate, and verifying the route (D) is unnecessary as IM is specified.
The client states, 'My discharge plan leaves me with a lot to do. I don't think I can do it. I'm never good at doing things.' The nurse knows the client lacks:
- A. maturation.
- B. organization.
- C. readiness to learn.
- D. self-efficacy.
Correct Answer: D
Rationale: Expressing doubt in ability to manage the discharge plan indicates low self-efficacy, a belief in one's capacity to execute tasks.
Mr. Smith is 67-year-old black male brought to the hospital by his wife, who stated that he fell down 20 minutes ago and has been unable to speak or move his right side since then, Mr. Smith has no significant past medical history. On exam, Mr. Smith is conscious, very anxious, his speech is garbed and unintelligible, he has a left facial droop, and he is completely right hemiphlegic.
The most likely etiology for his symptoms is:
- A. CVA
- B. Traumatic brain injury
- C. Brain tumor
- D. Alzheimer's disease
Correct Answer: A
Rationale: Symptoms of sudden speech loss, facial droop, and hemiplegia strongly suggest a cerebrovascular accident (stroke).
A nurse is caring for a patient with major depressive disorder. Which of the following interventions is most appropriate?
- A. Encourage the patient to spend time alone
- B. Discourage the patient from expressing feelings
- C. Encourage participation in group activities
- D. Avoid discussing the patient's feelings
Correct Answer: C
Rationale: Group activities promote socialization and reduce isolation in depression, supporting recovery. Encouraging alone time or avoiding feelings worsens symptoms, and expression should be encouraged therapeutically.