Nokea
The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention?
- A. The cuff wraps around the girth of the leg.
- B. The UAP auscultates the popliteal pulse with the cuff on the lower leg.
- C. The client is placed in a prone position.
- D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.
Correct Answer: B
Rationale: When obtaining blood pressure in the lower extremities, the popliteal pulse should be auscultated when the blood pressure cuff is applied around the thigh. The nurse should intervene when the UAP is auscultating the popliteal pulse with the cuff on the lower leg because this is incorrect placement. Option A, wrapping the cuff around the girth of the leg, ensures an accurate assessment. Option C, placing the client in a prone position, provides the best access to the artery. The systolic pressure in the popliteal artery is typically 10 to 40 mm Hg higher than in the brachial artery, so a systolic reading 20 mm Hg higher than the blood pressure in the client's arm is within the expected range and does not require intervention.
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A client on the psychiatric unit begins to pace and continuously wring hands, and the nurse notes the client's voice is becoming louder and angrier. Which action does the nurse take?
- A. Utilize an organized team to place the client in seclusion.
- B. Allow time in the client's private assigned room for reflection.
- C. Redirect the client to a quiet activity such as journaling.
- D. Assist the client to express feelings of anger and frustration.
Correct Answer: D
Rationale: Assisting the client to express feelings helps de-escalate agitation by addressing the underlying emotions, promoting safety and therapeutic communication. Seclusion is a last resort, reflection may not address acute agitation, and journaling may not be feasible in this state.
The nurse is developing a plan of care for a client scheduled for an above-the-knee leg amputation. Which action should the nurse include in the plan of care when addressing the psychosocial needs of the client?
- A. Explain to the client that open grieving is abnormal.
- B. Encourage the client to express feelings about body changes.
- C. Advise the client to seek psychological treatment after surgery.
- D. Discourage sharing with others who have had similar experiences.
Correct Answer: B
Rationale: Surgical incisions or the loss of a body part can alter a client's body image. The onset of problems coping with these changes may occur during the immediate or extended postoperative stage. Nursing interventions primarily involve providing psychological support. The nurse should encourage the client to express how he or she feels about these postoperative changes that will affect his or her life. Option 1 is an incorrect statement because open grieving is normal. Option 3 indicates disapproval, and in option 4, the nurse is giving advice.
The rehabilitation nurse witnessed a postoperative client who had a coronary artery bypass graft and his spouse arguing after a rehabilitation session. Which would be the most appropriate therapeutic statement for the nurse to make to identify the feelings of the client?
- A. You seem upset.'
- B. Oh, don't let this get you down.'
- C. It will seem better tomorrow. Now smile.'
- D. You shouldn't get upset. It'll affect your heart.'
Correct Answer: A
Rationale: Acknowledging the client's feelings without inserting your own values or judgments is a method of therapeutic communication. Therapeutic communication techniques assist with the flow of communication, and they always focus on the client. Option 1 is an open-ended statement that allows the client to verbalize, which gives the nurse a direction or clarification of the client's true feelings. The remaining options do not encourage verbalization by the client.
The nurse is teaching a group of women at a community center about risk factors for spousal abuse. Which would the nurse identify as risk factors? Select all that apply.
- A. alcohol or drug use
- B. low income or poverty
- C. being over the age of 40
- D. a higher level of education
- E. having a large circle of friends
- F. pregnancy, especially if it is unplanned
Correct Answer: A,B,F
Rationale: Alcohol/drug use, poverty, and unplanned pregnancy are established risk factors for spousal abuse. Age, education, and social circles are not specific risk factors.
The client prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct?
- A. Place the client in a high Fowler position.
- B. Assist the client in assuming a left side-lying position.
- C. Measure the tube from the tip of the nose to the xiphoid process.
- D. Assist the client in flexing the neck forward to facilitate tube insertion.
Correct Answer: A
Rationale: The correct intervention during nasogastric tube insertion in an awake and alert client is to place them in a high Fowler position (A). Left side-lying position (B) is more suitable for unconscious or obtunded clients. When measuring the tube length, it should be from the tip of the nose to behind the ear, and then from behind the ear to the xiphoid process (C). Assisting the client in flexing the neck forward (D) is appropriate to facilitate tube insertion rather than extending the neck back, which may lead to complications. Proper positioning and measurements are crucial to prevent complications and ensure successful nasogastric tube placement.