Nokea
The nurse on the medical/surgical unit cares for a client with a diagnosis of cerebrovascular accident (CVA). The nursing assessment of the client's neurological status should include which of the following? (Select all that apply)
- A. Obtain the pulses in all four extremities
- B. Ask the client to grasp and squeeze two fingers on each of the nurse's hands
- C. Determine the client's orientation to person, place, and time
- D. B, C
Correct Answer: D
Rationale: The correct answer is 'D' because assessing grasp strength (choice B) and orientation to person, place, and time (choice C) are crucial components of a neurological assessment following a cerebrovascular accident (CVA). Pulse assessment in all four extremities (choice A) is not directly related to a neurological assessment and is more pertinent to vascular status. Therefore, choices A and D are incorrect in this context.
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When a patient is prescribed an oral anticoagulant, what should the nurse monitor for?
- A. Elevated blood glucose
- B. Decreased blood pressure
- C. Signs of bleeding
- D. Increased appetite
Correct Answer: C
Rationale: When a patient is prescribed an oral anticoagulant, the nurse should monitor for signs of bleeding. Oral anticoagulants work by inhibiting the blood's ability to clot, which increases the risk of bleeding. Monitoring for signs of bleeding such as easy bruising, petechiae, hematuria, or bleeding gums is crucial to prevent complications. Elevated blood glucose (Choice A) is not directly related to oral anticoagulant use. Decreased blood pressure (Choice B) is not a common effect of oral anticoagulants. Increased appetite (Choice D) is not a typical side effect of oral anticoagulants and is not a primary concern when monitoring a patient on this medication.
The client is recovering from a percutaneous renal biopsy. Which data indicate that the client is complying with client teaching?
- A. The client lies flat in the supine position for 12 hours
- B. The client continues oral fluids restriction while on bed rest
- C. The client's family changed the dressing on return to the room
- D. The family activates the patient-controlled analgesia pump
Correct Answer: A
Rationale: The correct answer is A. Lying flat in the supine position for 12 hours after a renal biopsy helps prevent bleeding, which is crucial for the client's recovery. This position aids in applying pressure to the biopsy site, reducing the risk of bleeding and ensuring optimal healing. Choices B, C, and D do not directly relate to compliance with client teaching after a renal biopsy. Continuing oral fluids restriction, changing the dressing, or activating a patient-controlled analgesia pump are not specific instructions aimed at promoting recovery and preventing complications post renal biopsy.
Which of the following is NOT one of the three basic areas of concern into which practical nurse management responsibilities can be categorized?
- A. Managing patients' legal affairs
- B. Managing the hypothalamus: The hypothalamus is a small area in the brain located just below the thalamus. It plays a crucial role in controlling various bodily functions, including temperature regulation, hunger, and thirst, sleep-wake cycles, and hormone regulation. The hypothalamus is also involved in the control of the autonomic nervous system and the release of hormones from the pituitary gland.
- C. Managing work center operations
- D. Managing personnel
Correct Answer: A
Rationale: Managing patients' legal affairs is not a basic area of concern in practical nurse management responsibilities. The primary areas typically include managing work center operations, managing personnel, and overseeing patient care. Choice B, managing the hypothalamus, is irrelevant to nurse management responsibilities and is not a standard area of concern in this context. Choice C, managing work center operations, and Choice D, managing personnel, align more closely with the core responsibilities and concerns of practical nurse management roles.
Which laboratory data indicate the client's pancreatitis is improving?
- A. The amylase and lipase serum levels are decreased
- B. The white blood cell count (WBC) is decreased
- C. The conjugated and unconjugated bilirubin levels are decreased
- D. The blood urea nitrogen (BUN) serum level is decreased
Correct Answer: A
Rationale: The correct answer is A. Amylase and lipase are specific markers for pancreatitis. A decrease in their serum levels indicates improvement in pancreatitis. Choice B, a decreased white blood cell count (WBC), is more indicative of an improvement in infection rather than pancreatitis. Choices C and D, decreased bilirubin levels and blood urea nitrogen (BUN) levels respectively, are not specific markers for pancreatitis improvement.
Which medication should a patient with a history of peptic ulcer disease avoid?
- A. Acetaminophen
- B. Antacids
- C. Nonsteroidal anti-inflammatory drugs
- D. Antihistamines
Correct Answer: C
Rationale: Patients with a history of peptic ulcer disease should avoid Nonsteroidal anti-inflammatory drugs (NSAIDs) because they can worsen peptic ulcers due to their effects on the stomach lining. Acetaminophen (Choice A) is a safer alternative for pain relief in such patients as it does not have the same ulcerogenic effects. Antacids (Choice B) can actually help alleviate symptoms by neutralizing stomach acid and are generally safe to use. Antihistamines (Choice D) are not known to exacerbate peptic ulcers and can be used safely for conditions like allergies.