Nokea
The nurse is preparing to administer an IM dose of vitamin B1 (Thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, "What do you think you're doing?" How should the nurse respond?
- A. "I cannot give you this medication until you calm down."
- B. "This shot will help relieve the pain in your feet."
- C. "Would you prefer to learn to administer your own shot?"
- D. "You will feel calmer and less jittery after this shot."
Correct Answer: B
Rationale: The correct response is to provide a relevant explanation to the client. Choice B, "This shot will help relieve the pain in your feet," is the best answer because it directly addresses the client's concern about the purpose of the medication. By explaining the potential benefit of the injection, the nurse can alleviate the client's anxiety and increase their cooperation during the procedure. Choice A is incorrect as it dismisses the client's question and may escalate the situation. Choice C is not suitable as it deviates from addressing the client's immediate query. Choice D is incorrect because it fails to specifically address the client's concern regarding the medication's purpose.
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A 3-year-old boy was successfully toilet trained prior to his admission to the hospital for injuries sustained from a fall. His parents are very concerned that the child has regressed in his toileting behaviors. Which information should the nurse provide to the parents?
- A. Children usually resume their toileting behaviors when they leave the hospital
- B. A retraining program will need to be initiated when the child returns home
- C. Diapering will be provided since hospitalization is stressful to preschoolers
- D. A potty chair should be brought from home so he can maintain his toileting skills
Correct Answer: A
Rationale: Children often regress in toileting behaviors during hospitalization due to stress and changes in routine. However, they usually resume normal behaviors once they are discharged and back in their familiar environment. Providing reassurance to the parents that the child is likely to return to his previous toileting habits after leaving the hospital can help alleviate their concerns. Choices B, C, and D are incorrect because they do not address the normal pattern of behavior regression and recovery in toileting skills associated with hospitalization.
After medicating the client for pain and collecting granules and stones from strained urine, which action is most important for the nurse to implement next?
- A. Send the calculi for laboratory analysis of stone composition.
- B. Evaluate the client for persistent pain.
- C. Assess the clarity of urine.
- D. Encourage high fluid intake to produce urine output of 2L/day.
Correct Answer: A
Rationale: Sending the calculi for analysis is crucial in determining the type of stone present. Identifying the stone composition helps in developing an effective treatment plan and preventive measures to avoid future episodes of urolithiasis. This step is essential in providing targeted care for the client. Options B, C, and D are not the most important actions at this point. While evaluating for persistent pain is essential, determining the stone composition takes precedence to guide appropriate interventions.
The nurse is assessing a client with Addison's disease who is weak, dizzy, disoriented, and has dry oral mucous membranes, poor skin turgor, and sunken eyes. Vital signs are blood pressure 94/44, heart rate 123 beats/minute, respiration 22 breaths/minute. Which intervention should the nurse implement first?
- A. Assess extremity strength and resistance
- B. Report a sodium level of 132 mEq/L or mmol/L (SI units)
- C. Measure and record the cardiac QRS complex
- D. Check current finger stick glucose
Correct Answer: D
Rationale: The client's symptoms suggest possible adrenal crisis or hypoglycemia. Checking glucose is a priority to rule out hypoglycemia, which requires immediate intervention. The client is presenting with symptoms indicative of hypoglycemia, which can be life-threatening if not promptly addressed. Assessing extremity strength, reporting sodium levels, or measuring the cardiac QRS complex are not the most urgent actions in this scenario.
A client is admitted to the intensive care unit with diabetes insipidus due to a pituitary gland tumor. Which potential complication should the nurse monitor closely?
- A. Hypokalemia
- B. Ketonuria
- C. Peripheral edema
- D. Elevated blood pressure
Correct Answer: A
Rationale: The correct answer is A: Hypokalemia. In diabetes insipidus, there is excessive urination leading to fluid loss, which can result in electrolyte imbalances such as hypokalemia. Monitoring potassium levels is crucial to prevent complications like cardiac arrhythmias. Choices B, C, and D are incorrect. Ketonuria is typically seen in diabetic ketoacidosis, peripheral edema is more commonly associated with conditions like heart failure or kidney disease, and elevated blood pressure is not a direct complication of diabetes insipidus related to a pituitary gland tumor.
Which type of wound would most likely require immediate intervention by the healthcare provider?
- A. Laceration
- B. Abrasion
- C. Contusion
- D. Ulceration
Correct Answer: A
Rationale: A laceration would most likely require immediate intervention by the healthcare provider due to its deeper tissue damage, significant bleeding, and higher risk of infection compared to abrasions, contusions, and ulcerations. Lacerations often need prompt attention to control bleeding, clean the wound, and reduce the risk of infection. Abrasions are superficial wounds that usually do not require urgent attention as they tend to heal well on their own with basic wound care. Contusions are bruises that typically resolve on their own without immediate intervention. Ulcerations are open sores that may require intervention but not necessarily immediate action unless complicated by infection or other issues.