Nokea
The nurse observes that a client has difficulty chewing and swallowing her food. A nursing response designed to reduce this problem would include:
- A. Ordering a full liquid diet for her
- B. Ordering five small meals for her
- C. Ordering a mechanical soft diet for her
- D. Ordering a puréed diet for her
Correct Answer: C
Rationale: A mechanical soft diet is easier to chew and swallow due to its consistent texture, making it appropriate before trying a puréed diet.
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The cardiac client who exhibits the symptoms of disorientation, lethargy, and seizures may be exhibiting a toxic reaction to:
- A. Digoxin (Lanoxin)
- B. Lidocaine (Xylocaine)
- C. Quinidine gluconate or sulfate (Quinaglute, Quinidex)
- D. Nitroglycerin IV (Tridil)
Correct Answer: B
Rationale: Side effects of digoxin include headache, hypotension, AV block, blurred vision, and yellow-green halos. Side effects of lidocaine include heart block, headache, dizziness, confusion, tremor, lethargy, and convulsions. Side effects of quinidine include heart block, hepatotoxicity, thrombocytopenia, and respiratory depression. Side effects of nitroglycerin include postural hypotension, headache, dizziness, and flushing.
The nurse receives report on the group of clients listed here. Place the client list in sequential priority order for the nurse to assess. (Most important for the nurse to assess first, second, third, and fourth.)
- A. Client admitted from the emergency room previous shift with unrelieved migraine headache.
- B. Client transferred from surgical intensive care after traumatic brain injury. Pulse oximetry reading 94%.
- C. Client with a Glasgow coma scale (GCS) of 5 with evidence of cerebral aneurysm rupture on CT scan.
- D. Client admitted from the emergency room after a motor vehicle accident and GCS of 13
Correct Answer: C, B, D, A
Rationale: Priority: GCS 5 with aneurysm (C) is life-threatening, followed by traumatic brain injury (B, potential deterioration), motor vehicle accident with GCS 13 (D, stable but needs monitoring), and migraine (A, non-emergent).
On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which one of the following nursing actions is essential at this time?
- A. Administer her next dosage of lithium, and then call the physician.
- B. Withhold her lithium, and report her symptoms to the physician.
- C. Place her on NPO to decrease the excretion of lithium from her body, and call the physician.
- D. Contact the lab and request a lithium level in 30 minutes, and call the physician.
Correct Answer: B
Rationale: The client has lithium toxicity, and the nurse must withhold further dosages. Because of her level of toxicity, further lithium could cause coma and death. The nurse needs further orders from the physician to stabilize the client's lithium level.
A 23-year-old college student seeks medical attention at the college infirmary for complaints of severe fatigue. Her skin is pale, and she reports exertional dyspnea. She is admitted to the hospital with possible aplastic anemia. Laboratory values reflect anemia, and the client is prepared for a bone marrow biopsy. She refuses to sign the biopsy consent and states, 'Can't you just get the doctor to give me a transfusion and let me go. This weekend begins spring break, and I have plans to go to Florida.' At this time the nurse's greatest concern is that:
- A. The client may contract an infection as a result of being exposed to large crowds at spring break
- B. The client does not grasp the full impact of her illness
- C. The client may require transfusion before leaving for spring break
- D. The causative agent be identified and treatment begun
Correct Answer: B
Rationale: The client could contract an infection, but at this point it is not the most pertinent issue. The client's statement indicates that she does not grasp the full impact of her illness. Further client education must be given, along with allowing her to express her feelings regarding her illness. The client may require a transfusion, but this is a temporary measure because the causative agent has not been identified. Her feelings regarding her illness must be addressed in order for care to continue. A bone marrow is done first to make a definitive diagnosis; then treatment may begin.
A client with a history of osteoarthritis is admitted with complaints of joint stiffness. The nurse should expect the client to have:
- A. Pain with activity
- B. Morning stiffness lasting hours
- C. Symmetrical joint involvement
- D. Systemic symptoms like fever
Correct Answer: A
Rationale: Osteoarthritis causes joint pain worsened by activity due to cartilage degeneration, unlike rheumatoid arthritis, which involves prolonged morning stiffness.