Nokea
The nurse working in a surgeon's office receives all of the following messages from the answering service. Which client should be called back first?
- A. An adult who had an inguinal hernia repair yesterday states that he is having trouble urinating.
- B. An adult who had an appendectomy yesterday says the pain medication makes her sleepy.
- C. An adult who had abdominal surgery two weeks ago wants to know if she can drive a car.
- D. An adult who had a laparoscopic cholecystectomy two days ago says the adhesive bands fell off the incisions.
Correct Answer: A
Rationale: Difficulty urinating post-hernia repair may indicate urinary retention, a potential complication requiring urgent attention. Other issues are less immediate.
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Which client data should the nurse act upon when a home health aide calls the nurse from the client's home to report these items?
- A. The client has complaints of not sleeping well for the past week
- B. The family wants to discontinue the home meal service, meals on wheels
- C. The urine in the client has been cloudy for the last 2 days
- D. The partner says the client has slower days every other day
Correct Answer: C
Rationale: Home health aides need to report diverse information to nurses through phone calls and documentation. The nurse who develops the plan of care for a specific client, and supervises the aide, must identify potential danger signs which require immediate action and follow-up. The color of the urine requires follow-up evaluation.
A 25-year-old man is in an acute manic episode. The nurse knows that which client behavior would be MOST characteristic of mania?
- A. Agitation, grandiose delusions, euphoria, difficulty concentrating.
- B. Difficulty in decision-making, preoccupation with self, distorted perceptions.
- C. Paranoia, hallucinations, disturbed thought processes, hypervigilance.
- D. Fear of going crazy, somatic complaints, difficulties with intimacy, increased anxiety.
Correct Answer: A
Rationale: characteristic behaviors associated with an acute manic episode include agitation, grandiose delusions, euphoria, and concentration problems; mania is a mood of extreme euphoria and is manifested by more extreme levels of behavior
A client with a perforated bowel secondary to a bowel obstruction.
At the time the diagnosis is made, which of the following should be a priority in the nursing care plan?
- A. Maintain the client in a supine position.
- B. Notify the client's next-of-kin.
- C. Prepare the client for emergency surgery.
- D. Remove the nasogastric tube.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) client is kept in semi-Fowler's position (2) not a priority action (3) correct-when the bowel perforates as a result of increased intraluminal pressure within the gut, inTest inal contents are released into the peritoneum, leading to peritonitis (4) should not be done
Following a coronary artery bypass, a client develops a temperature of 102°. The nurse should notify the doctor because an elevation in temperature:
- A. Increases the cardiac output
- B. Decreases the cardiac output
- C. Indicates a cardiac tamponade
- D. Increases diaphoresis and the likelihood of hypothermia
Correct Answer: B
Rationale: A fever increases metabolic demand, which can decrease cardiac output in a post-bypass patient, potentially straining the heart.
The nurse is working on a plan to assist an abused client back into the work situation. Which will likely be most helpful in decreasing the trauma for the client?
- A. Support from significant others
- B. Support from a counselor
- C. Support from friends
- D. Support from coworkers
Correct Answer: A
Rationale: Support from significant others provides emotional stability, most effective in reducing trauma for an abused client re-entering work.