Nokea
Upon admission to the stroke care unit of a rehabilitation center, what is the primary action of the nurse?
- A. Collect and organize documents for the client's medical record
- B. Prepare the client's identification bracelet
- C. Identify pertinent health history data and current needs and limitations
- D. Gather the client's valuables and secure them in a locked container
Correct Answer: C
Rationale: The correct answer is C because identifying pertinent health history data and current needs and limitations is crucial in developing an individualized care plan for the stroke patient. This data helps determine the appropriate interventions and therapies needed for the client's recovery. Collecting and organizing documents (choice A) can be important but not the primary action. Preparing an identification bracelet (choice B) and gathering valuables (choice D) are important tasks but not the immediate priority upon admission.
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Which behavior observed by the nurse indicates a suspicion that a depressed adolescent client may be suicidal?
- A. The adolescent gives away a DVD player and a cherished autographed picture of a performer.
- B. The adolescent runs out of group therapy, swearing at the group leader, and then goes to her room.
- C. The adolescent becomes angry while speaking on the phone and slams down the receiver.
- D. The adolescent gets angry with her roommate when the roommate borrows her clothes without asking.
Correct Answer: A
Rationale: The correct answer is A because giving away cherished possessions can be a sign of preparing for suicide. This behavior may indicate a lack of concern for material possessions due to a belief that they won't be needed in the future. Choice B shows anger and isolation, not necessarily suicidal ideation. Choice C demonstrates anger but no indication of suicidal thoughts. Choice D shows anger towards the roommate, not self-harm intentions.
The nurse is performing discharge teaching for Mrs. S after cardiac angioplasty. Her husband is present for the teaching. While explaining the prescription for antiplatelet medication to use at home, Mrs. S's husband states, 'I don't think I can afford to refill that medication.' What is the most appropriate response of the nurse?
- A. Don't worry, your insurance will cover it.
- B. I'll ask the physician if he can prescribe a medication that is more affordable.
- C. You should apply for Medicare to see if they can help you.
- D. This medication is essential for her care and should be given priority over all others that she is taking.
Correct Answer: B
Rationale: The most appropriate response of the nurse is option B: "I'll ask the physician if he can prescribe a medication that is more affordable." This response demonstrates empathy towards the husband's concerns about affordability and shows willingness to explore alternative solutions. It acknowledges the financial constraint without making assumptions about insurance coverage or suggesting a specific program like Medicare. It also shows collaboration by involving the physician in finding a suitable alternative medication. The other choices are incorrect because they do not directly address the husband's affordability concern or offer a proactive solution to the issue.
A client is admitted with the diagnosis of pulmonary embolism. While taking a history, the client tells the nurse he was admitted for the same thing twice before, the last time just 3 months ago. The nurse would anticipate the healthcare provider ordering:
- A. Pulmonary embolectomy
- B. Vena caval interruption
- C. Increasing the coumadin therapy to achieve an INR of 3-4
- D. Thrombolytic therapy
Correct Answer: B
Rationale: The correct answer is B: Vena caval interruption. In this scenario, the client has a history of recurrent pulmonary embolism, indicating a high risk for further episodes. Vena caval interruption, such as with an inferior vena cava filter, is a preventive measure to reduce the risk of pulmonary embolism recurrence by trapping blood clots before they reach the pulmonary circulation. This intervention is indicated when anticoagulation alone is not sufficient to prevent further emboli. Pulmonary embolectomy (A) is a surgical procedure to remove a clot from the pulmonary artery and is typically reserved for massive, life-threatening embolisms. Increasing coumadin therapy (C) to achieve a higher INR may increase bleeding risk without necessarily preventing future emboli. Thrombolytic therapy (D) is reserved for acute, large emboli causing hemodynamic instability.
Which example best describes the concept of beneficence?
- A. A nurse provides pain medication for a client in the recovery room who is experiencing pain
- B. A client has an advanced directive in place stating that he does not want intubation if he needs CPR
- C. At the request of the client, a nurse does not inform the family about his cancer diagnosis
- D. A nurse withholds narcotic medication for a client in pain, knowing that he is currently disoriented
Correct Answer: A
Rationale: The correct answer is A because beneficence refers to the ethical principle of doing good and promoting the well-being of the patient. Providing pain medication to a client in the recovery room aligns with this principle as it aims to alleviate suffering and improve the client's comfort. This action demonstrates a commitment to the client's best interests and upholds the duty of care.
Choice B is incorrect because it relates to autonomy, where the client's wishes regarding medical treatment are respected. Choice C is incorrect as it violates the principle of veracity by withholding important information from the family. Choice D is incorrect as it goes against beneficence by not addressing the client's pain adequately.
Which of the following tasks may be delegated to unlicensed assistive personnel?
- A. Cleansing a wound with peroxide
- B. Irrigating a colostomy
- C. Assisting with performing incentive spirometry
- D. Removing a saline-lock IV
Correct Answer: C
Rationale: The correct answer is C. Assisting with performing incentive spirometry can be delegated to unlicensed assistive personnel (UAP) as it involves a non-invasive procedure that does not require specialized training or licensure. UAP can help patients with using the incentive spirometer to improve lung function under the supervision of a licensed healthcare provider. Choices A, B, and D involve tasks that require specific skills and knowledge to prevent complications, hence should be performed by licensed healthcare professionals.