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To reduce the risk of venous thrombosis, which measure should the nurse instruct the client in to promote venous return?
- A. Instruct in the use of the incentive spirometer.
- B. Elevate the head of the bed during all meals.
- C. Use aseptic technique to change the dressing.
- D. Encourage frequent ambulation in the hallway.
Correct Answer: D
Rationale: To prevent venous thrombus formation, promoting venous return is crucial. Encouraging frequent ambulation in the hallway helps prevent venous stasis and reduces the risk of thrombus formation in immobile clients. Option A (using the incentive spirometer) aids in alveolar expansion to prevent atelectasis, not specifically venous thrombosis. Option B (elevating the head of the bed during meals) reduces the risk of aspiration, not venous thrombosis. Option C (using aseptic technique for dressing changes) reduces the risk of postoperative infection, not specifically venous thrombosis. Therefore, among the options provided, encouraging frequent ambulation in the hallway is the most effective measure to prevent venous thrombosis.
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Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?
- A. Perform cough and deep breathing exercises hourly.
- B. Turn from side to side in bed at least every 2 hours.
- C. Dorsiflex and plantarflex the feet 10 times each hour
- D. Drink approximately 4 ounces of water every hour
Correct Answer: C
Rationale: To reduce the risk of venous thrombosis, the nurse should instruct the client to perform dorsiflexion and plantar flexion exercises regularly. These exercises help promote venous return and prevent venous thrombus formation. Options A, B, and D are beneficial in managing other complications of immobility, such as atelectasis and pressure ulcers, but they are less effective in preventing venous thrombosis compared to dorsiflexion and plantar flexion exercises.
Which of the following is a nursing intervention for a client who is experiencing an acute panic attack?
- A. Encourage the client to sit down in a quiet environment
- B. Allow the client to direct the situation
- C. Try to focus the client on one aspect of care, such as regulating breathing patterns
- D. Speak in a commanding tone of voice to get the client's attention
Correct Answer: C
Rationale: When assisting a client with an acute panic attack, the primary goal is to help reduce their anxiety levels. Encouraging the client to focus on one controllable aspect, like regulating breathing patterns, can aid in calming them down. This intervention helps the client to regain control over their breathing, which can alleviate some of the symptoms associated with panic attacks. Options A and B are incorrect because allowing the client to direct the situation or sit down in a quiet environment may not be beneficial during an acute panic attack. Option D is inappropriate as speaking in a commanding tone can further escalate the client's anxiety rather than helping to calm them down.
The emergency room nurse admits a child who experienced a seizure at school. The father comments that this is the first occurrence and denies any family history of epilepsy. What is the best response by the nurse?
- A. Do not worry. Epilepsy can be treated with medications.
- B. The seizure may or may not mean your child has epilepsy.
- C. Since this was the first convulsion, it may not happen again.
- D. Long-term treatment will prevent future seizures.
Correct Answer: B
Rationale: The correct response is, 'The seizure may or may not mean your child has epilepsy.' There are various potential causes for a childhood seizure, such as fever, central nervous system conditions, trauma, metabolic alterations, and idiopathic reasons. It's essential not to jump to conclusions about epilepsy based on one seizure. Options A, C, and D provide premature or inaccurate information. Option A may give false reassurance without proper evaluation, option C assumes one seizure guarantees no recurrence, and option D oversimplifies treatment outcomes.
Which of the following actions is most appropriate when working with a client who is extremely angry?
- A. Place a light hand on the client's shoulder to convey understanding
- B. Maintain close proximity to build trust
- C. Temporarily change the subject if the client's behavior is escalating
- D. Close the door to the room to ensure privacy
Correct Answer: C
Rationale: When dealing with an angry client, it is crucial to employ techniques that can help de-escalate the situation or ensure safety while providing care. If the client's behavior is escalating or they are fixating on a particular topic that is fueling their anger, it is advisable to temporarily change the subject. This technique can serve as a distraction from the initial trigger, allowing the client to refocus their thoughts and emotions. Placing a hand on the client's shoulder may not be well-received as physical touch can escalate the situation. Maintaining close proximity might be perceived as confrontational rather than building trust. Closing the door for privacy is important but may not directly address the client's anger or help in de-escalation.
A client comes into the emergency room and asks to see a doctor. He is anxious, visibly upset, and keeps looking behind him to the waiting room. When the nurse asks his chief complaint, he says, 'My roommate is trying to kill me.' Which of the following is the most appropriate initial response of the nurse?
- A. Just wait here and I will notify security.
- B. I'm going to speak with the physician about getting some medication that may help you.
- C. Why is your roommate trying to kill you?
- D. Have you called the police to report this?
Correct Answer: C
Rationale: Upon initial assessment of a client who appears anxious and upset, with claims that need further exploration, the nurse's initial response should be to gather more information about the situation. By asking 'Why is your roommate trying to kill you?' the nurse shows empathy while trying to understand the patient's perspective. This open-ended question allows the nurse to assess the situation comprehensively. Options A and D jump to conclusions or suggest actions without understanding the situation. Option B focuses solely on medication without addressing the underlying issue. It is crucial to assess the situation further before taking any action or providing treatment.