Nokea
The nurse’s INITIAL priority when managing a physically assaultive client is to
- A. What is the initial priority when managing a physically assaultive client?
- B. Restrict the client to the room.
- C. Place the client under one-to-one supervision.
- D. Restore the client’s self-control and prevent further loss of control.
- E. Clear the immediate area of other clients to prevent harm.
Correct Answer: C
Rationale: Restoring the client’s self-control is the initial priority to ensure safety and prevent escalation. This involves assessing the situation, using psychological or chemical interventions, and possibly physical control. Room restriction, supervision, or clearing the area are secondary or impractical during rapid escalation.
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The nurse is assisting the RN to develop a nursing care plan for a client who has acute glomerulonephritis. Which of the following should the nurse monitor? Select all that apply.
- A. Urine for protein
- B. Urine for specific gravity
- C. Intake and output
- D. Daily weights
- E. Blood pressure
- F. Serum electrolytes
Correct Answer: A,B,C,D,E,F
Rationale: Glomerulonephritis causes proteinuria, altered urine concentration, fluid retention, hypertension, and electrolyte imbalances; monitoring urine, intake/output, weight, BP, and electrolytes tracks disease progression and complications.
A 9-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of Syndeham's chorea?
- A. Irregular movements of the arms and legs and facial grimacing
- B. Painless swellings over the surface of the joints
- C. Faint areas of red demarcation over the back
- D. Swelling and inflammation of the joints
Correct Answer: A
Rationale: Syndeham's chorea is characterized by irregular, involuntary movements and facial grimacing, so A is correct. Answers B, C, and D describe other rheumatic fever symptoms but not chorea.
The nurse admits a client newly diagnosed with hypertension. What is the best method for assessing the blood pressure?
- A. Standing and sitting
- B. In both arms
- C. After exercising
- D. Supine position
Correct Answer: B
Rationale: In both arms. This ensures accuracy, as stenosis in one subclavian artery could cause a false reading.
On the third post-burn day, the nurse finds that the client's hourly urine output is 26 ml. The nurse should continue to assess the client and notify the doctor for an order to:
- A. Decrease the rate of the intravenous infusion.
- B. Change the type of intravenous fluid being administered.
- C. Change the urinary catheter.
- D. Increase the rate of the intravenous infusion.
Correct Answer: D
Rationale: The urinary output should be maintained between 30 ml and 50 ml per hour. The first action should be to increase the IV rate to prevent increased acidosis. Answer A would lead to diminished output, so it is incorrect. There is no indication that the type of IV fluid is not appropriate as is suggested by answer B, making it incorrect. Answer C would not increase the client's output and would place the client at greater risk for infection, so it is incorrect.
The nurse is conducting a community group discussion on nutrition. One of the participants says to the nurse, 'I am a vegan. I have been told I might get pernicious anemia. How can I prevent that?' What should the nurse include when answering the client?
- A. She is not at risk for pernicious anemia because there are many nonmeat sources of vitamin B12.
- B. She is at risk of developing pernicious anemia, but taking a vitamin supplement that contains vitamin B12 should prevent it.
- C. She should see her physician and ask about getting monthly injections of vitamin B12 because she is a risk for pernicious anemia.
- D. She should be tested for an enzyme that produces vitamin B12. If she is deficient, she should be treated with daily injections.
Correct Answer: B
Rationale: Vegans lack dietary B12 (found in animal products), risking pernicious anemia. Oral B12 supplements can prevent deficiency, while injections or enzyme testing are unnecessary unless absorption issues exist.