Nokea
The priority nursing goal when working with an autistic child is:
- A. To establish trust with the child
- B. To maintain communication with the family
- C. To promote involvement in school activities
- D. To maintain nutritional requirements
Correct Answer: A
Rationale: The priority nursing goal when working with an autistic child is establishing a trusting relationship. Maintaining a relationship with the family is important but having the trust of the child is a priority. To promote involvement in school activities is inappropriate for a child who is autistic. Maintaining nutritional requirements is not the primary problem of the autistic child.
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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).
The nurse is performing an assessment on a client with a history of pancreatitis. Which finding is most concerning?
- A. Abdominal tenderness
- B. Nausea and vomiting
- C. Fever of 101°F
- D. Grey-Turner’s sign
Correct Answer: D
Rationale: Grey-Turner’s sign (flank bruising) indicates retroperitoneal hemorrhage in pancreatitis, a life-threatening complication requiring immediate attention. Other findings are common but less severe.
A 35-year-old client is receiving psychopharmacological treatment of his major depression with tranylcypromine sulfate (Parnate), a monoamine oxidase (MAO) inhibitor. The nurse teaches the client that while he is taking this type of antidepressant, he needs to restrict his dietary intake of:
- A. Potassium-rich foods
- B. Tryptophan
- C. Tyramine
- D. Saturated fats
Correct Answer: C
Rationale: The client may need to avoid some potassium-rich foods (such as bananas, raisins, etc.). However, this is not because of the potassium content of these foods. Tryptophan is an essential amino acid that is present in high concentrations in animal and fish protein. The client will need to watch his dietary intake of tyramine. Tyramine is a by-product of the conversion of tyrosine to epinephrine. Tyramine is found in a variety of foods and beverages, ranging from aged cheese to caffeine drinks. Ingestion of tyramine-rich foods while taking a MAO inhibitor may lead to an increase in blood pressure and/or a life-threatening hypertensive crisis. To maintain a healthy lifestyle, restriction of dietary saturated fats is advisable.
A 70-year-old client is almost finished receiving her second unit of packed red blood cells. The client, who weighs 80 lb, has started complaining of being short of breath and now has crackles in the bases of her lungs. After slowing or stopping the transfusion, the most appropriate initial nursing action would be to:
- A. Raise the client's head and place her feet in a dependent position
- B. Notify the physician
- C. Place the client on 2 liters of O2 via nasal cannula
- D. Administer furosemide (Lasix) 20 mg IV push
Correct Answer: A
Rationale: Raising the head and placing feet in a dependent position reduces venous return and pulmonary congestion, addressing transfusion-related circulatory overload.
A client with a history of stroke is admitted with complaints of hemiparesis. The nurse should give priority to:
- A. Providing physical therapy
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering anticoagulants
Correct Answer: A
Rationale: Physical therapy improves strength and mobility in hemiparesis post-stroke, promoting recovery.