Nokea
The nurse observes a coworker acting erratically. The clients assigned to this coworker don’t seem to get relief when pain medications are administered. Which action should the nurse implement?
- A. Try to help the coworker by confronting the coworker with the nurse’s suspicions.
- B. Tell the coworker that the nurse will give all narcotic medications from now on.
- C. Report the nurse’s suspicions to the nurse’s supervisor or the facility’s peer review.
- D. Do nothing until the nurse can prove the coworker has been using drugs.
Correct Answer: C
Rationale: Erratic behavior and ineffective pain relief suggest possible drug diversion. Reporting to the supervisor or peer review (C) ensures proper investigation while protecting patients. Confronting (A) may escalate, taking over medications (B) doesn’t address the issue, and waiting for proof (D) risks harm.
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The wife of the client diagnosed with septic meningitis asks the nurse, 'I am so scared. What is meningitis?' Which statement would be the most appropriate response by the nurse?
- A. There is bleeding into his brain causing irritation of the meninges.'
- B. A virus has infected the brain and meninges, causing inflammation.'
- C. It is a bacterial infection of the tissues that cover the brain and spinal cord.'
- D. It is an inflammation of the brain parenchyma caused by a mosquito bite.'
Correct Answer: C
Rationale: Septic meningitis is a bacterial infection of the meninges (C). Bleeding (A) describes subarachnoid hemorrhage, viral meningitis (B) is aseptic, and mosquito-related inflammation (D) refers to encephalitis.
The experienced nurse is instructing the new nurse on subarachnoid hemorrhage. The nurse evaluates that the new nurse understands the information when the new nurse makes which statements? Select all that apply.
- A. “Subarachnoid hemorrhage is often associated with a rupture of a cerebral aneurysm.”
- B. “Subarachnoid hemorrhage occurs during sleep and is noticed when the client awakens.”
- C. “The client experiencing a subarachnoid hemorrhage may state having a severe headache.”
- D. “Tissue plasminogen activator (tPA) should be given to treat a subarachnoid hemorrhage.”
- E. “A subarachnoid hemorrhage often results in the cerebrospinal fluid appearing bloody.”
Correct Answer: A,C,E
Rationale: A subarachnoid hemorrhage is usually caused by rupture of a cerebral aneurysm. Ischemic stroke in older adults, not a subarachnoid hemorrhage, often occurs during sleep when circulation and BP decrease. Irritation of the meninges from bleeding into the subarachnoid spaces causes a severe headache. Thrombolytic therapy with tPA lyses clots and is contraindicated in subarachnoid hemorrhage. Bleeding into the subarachnoid space will cause the CSF to be bloody.
The client is at risk for septic emboli after being diagnosed with meningococcal meningitis. Which action by the nurse directly addresses this risk?
- A. Monitoring vital signs and oxygen saturation levels hourly
- B. Planning to give meningococcal polysaccharide vaccine
- C. Assessing neurological function with the Glasgow Coma Scale q2h
- D. Completing a thorough vascular assessment of all extremities q2h
Correct Answer: D
Rationale: Monitoring VS is indicated but does not address the complication of septic emboli. Immunization with the meningococcal polysaccharide vaccine (Menomune) is a preventive measure against meningitis and would not be included in treatment. Frequent neurological assessments are indicated but do not address the complication of septic emboli. Frequent vascular assessments will detect vascular compromise secondary to septic emboli. Early detection allows for interventions that will prevent gangrene and possible loss of limb.
The nurse is developing a plan of care for a client diagnosed with West Nile virus. Which intervention should the nurse include in this plan?
- A. Monitor the client’s respirations frequently.
- B. Refer to a dermatologist for treatment of maculopapular rash.
- C. Treat hypothermia by using ice packs under the client’s arms.
- D. Teach the client to report any swollen lymph glands.
Correct Answer: A
Rationale: Severe West Nile virus can cause neurological and respiratory complications, so monitoring respirations (A) is critical. Rash (B) is self-limiting, hypothermia (C) is not typical, and lymph glands (D) are not a primary concern.
The client is brought to the emergency department by the police for public disorderliness. The client reports feeling no pain and is unconcerned that the police have arrested him. The nurse notes the client has epistaxis and nasal congestion. Which substance should the nurse suspect the client has abused?
- A. Marijuana.
- B. Heroin.
- C. Ecstasy.
- D. Cocaine.
Correct Answer: D
Rationale: Cocaine (D) causes epistaxis, nasal congestion, and euphoria with pain insensitivity. Marijuana (A), heroin (B), and ecstasy (C) do not typically cause these nasal symptoms.