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To ensure safety while administering a nitroglycerine patch, what should the nurse do?
- A. Wear gloves
- B. Shave the area where the patch will be applied
- C. Wash the area thoroughly with soap and rinse with hot water
- D. Apply the patch to the buttocks
Correct Answer: A
Rationale: To protect herself, the nurse should wear gloves when applying a nitroglycerine patch or cream. Answer B is incorrect because shaving the area where the patch will be applied might abrade the skin, increasing the risk of irritation. Answer C is incorrect because washing with hot water can vasodilate the skin, potentially increasing the absorption of nitroglycerine. Nitroglycerine patches should be applied to areas above the waist, making answer D incorrect as applying it to the buttocks is not recommended.
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A 26-year-old single woman is knocked down and robbed while walking her dog one evening. Three months later, she presents at the crisis clinic, stating that she cannot put this experience out of her mind. She complains of nightmares, extreme fear of being outside or alone, and difficulty eating and sleeping. What is the best response by the nurse?
- A. "I will ask the physician to prescribe medication for you."?
- B. "That must have been a very difficult and frightening experience. It might be helpful to talk about it."?
- C. "In the future, you might walk your dog in a more populated area or hire someone else to take over this task."?
- D. "Have you thought of moving to a safer neighborhood?"?
Correct Answer: B
Rationale: Choice B is the best response as it provides empathy and encourages the client to talk about her experience, which can be therapeutic. This approach validates the client's feelings and offers support. By acknowledging the difficulty and fear experienced by the client, the nurse opens the door for the client to express her emotions and begin the process of coping with the trauma. Choices A, C, and D do not address the emotional impact of the traumatic event or provide an opportunity for the client to express her feelings and concerns. Choice A immediately jumps to medication without exploring other supportive interventions. Choice C focuses on practical solutions without addressing the client's emotional needs. Choice D suggests a drastic solution without considering the client's emotional state or preferences.
A client is admitted with a diagnosis of Multiple Drug Use. The nurse should plan care based on knowledge that
- A. Multiple drug use is common.
- B. People might use more than one drug to enhance the effect or relieve withdrawal symptoms.
- C. Combining alcohol and barbiturates can be dangerous due to their combined depressant effects.
- D. Assessment and intervention are more complex with multiple drug use due to the synergistic effects.
Correct Answer: B
Rationale: When caring for a client with Multiple Drug Use, it is important to understand that individuals may use more than one drug simultaneously or sequentially to enhance the effect of a particular drug or to relieve withdrawal symptoms. This practice is common among substance users. For example, heroin users may also consume alcohol, marijuana, or benzodiazepines. Combining drugs can have various effects, such as intensifying intoxication or alleviating withdrawal symptoms. It is crucial to recognize that multiple drug use can complicate assessment and intervention due to the diverse effects of different substances on the client's health. Option A is incorrect as multiple drug use is indeed common, not uncommon. Option C is incorrect because combining alcohol and barbiturates can be dangerous due to their combined depressant effects. Option D is incorrect because multiple drug use complicates assessment and intervention rather than making them easier, as the effects of different drugs on the client need to be carefully considered.
What is an effective intervention for a client diagnosed with Obsessive-Compulsive Disorder?
- A. Discussing the repetitive actions.
- B. Insisting the client not perform the repetitive act.
- C. Informing the client that the act is not necessary.
- D. Encouraging daily exercise.
Correct Answer: D
Rationale: An effective intervention for a client diagnosed with Obsessive-Compulsive Disorder is encouraging daily exercise. Obsessive-Compulsive Disorder is an anxiety disorder, and exercise can help release emotional energy, limit the time available for maladaptive behaviors, and direct the client's attention outward. Discussing the repetitive actions (choice A) may reinforce the behavior by providing attention to it. Insisting the client not to perform the repetitive act (choice B) can increase anxiety and resistance, as abruptly stopping the behavior may be challenging. Informing the client that the act is not necessary (choice C) may not address the underlying anxiety and could invalidate the client's experiences, leading to increased distress. Encouraging daily exercise is a proactive intervention that can help manage symptoms of Obsessive-Compulsive Disorder by addressing core features of the disorder and promoting overall well-being.
The licensed practical nurse assigned to the postpartum unit is preparing to administer Rhogam to a postpartum client. Which woman is not a candidate for RhoGam?
- A. A gravida IV para 3 that is Rh negative with an Rh-positive baby
- B. A gravida I para 1 that is Rh negative with an Rh-positive baby
- C. A gravida II para 0 that is Rh negative admitted after a stillbirth delivery
- D. A gravida IV para 2 that is Rh negative with an Rh-negative baby
Correct Answer: D
Rationale: The mothers in answers A, B, and C all require RhoGam as they are Rh negative with an Rh-positive baby or have experienced a stillbirth delivery, making them candidates for RhoGam injection. The mother in answer D is the only one who does not require Rhogam because she is Rh negative with an Rh-negative baby, eliminating the need for RhoGam administration.
The nurse is assigning staff for the day. Which assignment should be given to the nursing assistant?
- A. Taking the vital signs of the 5-month-old with bronchiolitis
- B. Taking the vital signs of the 10-year-old with a 2-day postappendectomy
- C. Administering medication to the 2-year-old with periorbital cellulitis
- D. Adjusting the traction of the 1-year-old with a fractured tibia
Correct Answer: B
Rationale: The most appropriate assignment for a nursing assistant is to take the vital signs of a stable patient. A 10-year-old with a 2-day postappendectomy is considered stable, and routine vital signs monitoring can be safely delegated to a nursing assistant. Clients with bronchiolitis, periorbital cellulitis, and a fractured tibia require more specialized care and assessment by a licensed nurse. Bronchiolitis involves an airway alteration, periorbital cellulitis indicates an infection, and a fractured tibia may raise concerns of abuse. Therefore, options A, C, and D are incorrect for delegation to a nursing assistant.