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A client is admitted to the trauma intensive care unit (ICU) with a gunshot wound of the neck. The client has a cervical level (C-4) spinal cord injury, is tearful, constantly complains of discomfort, and requests to be suctioned.
The nurse understands that the client's attention-seeking behaviors may be due to
- A. anger and frustration.
- B. awareness of vulnerability.
- C. increased social isolation.
- D. increased sensory stimulation.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) is not accurate for situation (2) correct-is experiencing an increased awareness of his physical vulnerability due to his spinal cord injury; fosters increased dependency needs that are real due to his injury; is trying to determine who is consistent and trustworthy for meeting his significant physical needs (3) is not accurate for situation (4) is not accurate for situation
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The nurse is preparing to discharge a client after an abdominal cholecystectomy for treatment of cholelithiasis. The client will go home with a T-tube in place. Which of the following statements, if made by the client to the nurse, indicates a need for further teaching?
- A. It will be great to finally get home, take a shower, and wash my hair.
- B. If the amount of drainage increases over the next several days, I should call my physician.
- C. I can resume swimming laps three times a week at my health club.
- D. I will check the skin around the tube once a day to see how it is doing.
Correct Answer: C
Rationale: Swimming submerges the T-tube, risking infection, indicating a need for further teaching. Options A, B, and D are correct: showering is allowed, increased drainage requires reporting, and daily skin checks prevent complications.
A client is admitted for a series of Test s to verify the diagnosis of Cushing's syndrome.
Which of the following assessment findings, if observed by the nurse, would support this diagnosis?
- A. Buffalo hump, hyperglycemia, and hypernatremia.
- B. Nervousness, tachycardia, and intolerance to heat.
- C. Lethargy, weight gain, and intolerance to cold.
- D. Irritability, moon face, and dry skin.
Correct Answer: A
Rationale: Strategy: Think about each answer choice and how it relates to Cushing's syndrome. (1) correct-Cushing's syndrome is characteristic of these assessments, as are weight gain, moon face, purple striae, osteoporosis, mood swings, and high susceptibility to infections (2) symptoms of hyperthyroidism (3) symptoms of hypothyroidism (myxedema) (4) symptoms of hypoparathyroidism
A patient has a Sengstaken-Blakemore tube in place. The nurse enters the room and finds the woman in respiratory distress.
It is MOST important for the nurse to
- A. notify the physician immediately to remove the tube.
- B. elevate the head of the bed and administer oxygen.
- C. cut the balloon ports and remove the tube.
- D. call a code and begin rescue breathing.
Correct Answer: C
Rationale: Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) need to remove tube immediately to provide for airway (2) does not provide a patent airway (3) correct-scissors always secured at the bedside, remove tube if observe signs of respiratory distress or airway obstruction caused by upward displacement of esophageal balloon (4) unnecessary to call code until respiratory arrest occurs, then establish a patent airway first
A client has a cataract removed from the left eye. Which of the following is an important nursing intervention in the immediate postoperative period?
- A. Position the client on the right side with the head slightly elevated.
- B. Place the client on the left side to protect the eye.
- C. Perform sensory neurological checks every two hours.
- D. Maintain complete bedrest for the first 48 hours.
Correct Answer: A
Rationale: Positioning on the right side with head elevation prevents pressure on the surgical eye, reducing complications. Options B, C, and D are incorrect.
The nurse is caring for a client who is ordered to be on bed rest for a prolonged period of time. What should be included in the nursing care plan to prevent venous stasis?
- A. Deep breathe and cough every two hours
- B. Range-of-motion exercises every shift
- C. Antiembolism stockings on legs
- D. Turn every two hours
Correct Answer: C
Rationale: Antiembolism stockings promote venous return, preventing stasis in bedridden clients. Breathing exercises, ROM, and turning address other complications but not venous stasis directly.