Nokea
The nurse is planning care for a client with the diagnosis of deep vein thrombosis (DVT) of the left leg. The client is experiencing severe edema and pain in the affected extremity. Which interventions should the nurse plan to implement in the care of this client? Select all that apply.
- A. Elevate the left leg.
- B. Apply moist heat to the left leg.
- C. Administer acetaminophen as prescribed.
- D. Ambulate in the hall three times per shift.
- E. Administer anticoagulation as prescribed.
Correct Answer: A,B,C,E
Rationale: Management of the client with DVT who is experiencing severe edema and pain includes bed rest; limb elevation; relief of discomfort with warm, moist heat and analgesics as needed; anticoagulant therapy; and monitoring for signs of pulmonary embolism. In current practice, activity restriction may not be prescribed if the client is receiving low-molecular-weight anticoagulation; however, some primary health care providers may still prefer bed rest for the client.
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The nurse is caring for a client with a diagnosis of a C-6 spinal cord injury during the spinal shock phase. Which action should the nurse implement when preparing the client to sit in a chair?
- A. Apply knee splints to stabilize the joints during transfer.
- B. Teach the client to lock the knees during the pivoting stage of the transfer.
- C. Administer a vasodilator in order to improve circulation of the lower limbs.
- D. Raise the head of the bed slowly to decrease orthostatic hypotensive episodes.
Correct Answer: D
Rationale: Spinal shock is a sudden depression of reflex activity in the spinal cord that occurs below the level of injury (areflexia). It is often accompanied by vasodilation in the lower limbs, which results in a fall in blood pressure upon rising. The client can have dizziness and feel faint. The nurse should provide for a gradual progression in head elevation while monitoring the blood pressure. The use of splints would impair the transfer. Clients with cervical cord injuries cannot lock their knees. A vasodilator would exacerbate the problem.
When the nurse manager encourages staff to provide input in the decision-making process, which leadership style is being demonstrated?
- A. Autocratic
- B. Situational
- C. Democratic
- D. Laissez-faire
Correct Answer: C
Rationale: The democratic style of leadership best empowers staff toward excellence because this style of leadership allows nurses to provide input regarding the decision-making process and an opportunity to grow professionally. The autocratic style of leadership is task oriented and directive. The leader uses his or her power and position in an authoritarian manner to set and implement organizational goals. Decisions are made without input from the staff. The situational leadership style uses a style depending on the situation and events. The laissez-faire style allows staff to work without assistance, direction, or supervision.
The nurse is planning activities for a client diagnosed with depression who was just admitted to the hospital. Which therapeutic action should be implemented as part of the nurse's plan?
- A. Provide an activity that is quiet and solitary in nature.
- B. Plan nothing until the client asks to participate in the milieu.
- C. Offer the client a menu of activities and insist that the client participate in all of them.
- D. Provide a structured daily program of activities and encourage the client to participate.
Correct Answer: D
Rationale: A depressed person is often withdrawn. In addition, the person experiences difficulty concentrating, loss of interest or pleasure, low energy and fatigue, and feelings of worthlessness and poor self-esteem. The plan of care needs to provide stimulation in a structured environment. Options 1 and 2 are restrictive and offer little or no structure and stimulation. The nurse should not insist that a client participate in all activities.
During the admission process of a client being admitted for surgery, the client asks the nurse if a living will, prepared 3 years ago, remains in effect. Which response is most appropriate for the nurse to provide the client?
- A. Yes, a living will never expires.
- B. You need to speak with an attorney.
- C. I will call someone to answer your question.
- D. If it accurately reflects your situation and wishes.
Correct Answer: D
Rationale: The client should discuss the living will with the primary health care provider (HCP) on a regular basis to ensure that it contains the client's current wishes and desires based on the client's current health status. Option 1 is incorrect. Although the client can consult an attorney if the living will must be changed, the accurate nursing response is to tell the client that a living will should be reviewed. Option 3 is not at all helpful to the client and is, in fact, a communication block and places the client's question on hold.
The clinic nurse wants to develop a teaching program for clients with a diagnosis of diabetes mellitus. Which strategy should the nurse initiate first in order to best meet the clients' needs?
- A. Assess the clients' functional abilities.
- B. Ensure that insurance will pay for participation in the program.
- C. Discuss the focus of the program with the multidisciplinary team.
- D. Include everyone who comes into the clinic in the teaching sessions.
Correct Answer: A
Rationale: Nurse-managed clinics focus on individualized disease prevention and health promotion and maintenance. Therefore, the nurse must first assess the clients and their needs to effectively plan the program. Options 2, 3, and 4 do not address the clients' needs related to the diagnosis.