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What is a priority when providing care for a patient with a newly inserted tracheostomy?
- A. Keeping the tracheostomy tube clean and dry
- B. Providing regular oral hygiene
- C. Monitoring for signs of infection and ensuring a patent airway
- D. Encouraging the patient to cough and deep breathe
Correct Answer: C
Rationale: When caring for a patient with a newly inserted tracheostomy, the priority is to monitor for signs of infection and ensure a patent airway. This is crucial to prevent complications such as airway obstruction or infection. While keeping the tracheostomy tube clean and dry is important for overall care, it is not the highest priority when compared to ensuring a patent airway. Providing regular oral hygiene is essential for the patient's comfort but takes a secondary role to maintaining airway patency. Encouraging the patient to cough and deep breathe may be beneficial but is not as critical as monitoring for infection and keeping the airway clear.
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The single mother of a child with a head injury is sitting at the child's bedside crying when the PN enters the room. The mother states, 'Why did this happen to my child? I just can't cope with this.' How should the PN respond?
- A. Ask her to share how the injury occurred to her child.
- B. Recommend that she remain calm and positive for her child.
- C. Express that the present situation must be overwhelming.
- D. Determine if someone else can help her cope with this tragedy.
Correct Answer: C
Rationale: Expressing empathy and acknowledging the mother's feelings helps in providing emotional support during a difficult time. This response validates her emotions and offers a comforting presence. Choice A is not appropriate as it focuses on gathering information rather than addressing the mother's emotional distress. Choice B may come off as dismissive of the mother's feelings and oversimplifies the complexity of the situation. Choice D shifts the responsibility to someone else instead of offering immediate support and comfort.
A nurse is caring for a client with schizophrenia who continues to repeat the last words heard. Which nursing problem should the nurse document in the medical record?
- A. Altered thought processes
- B. Impaired social interaction
- C. Risk for self-directed violence
- D. Disturbed thought processes
Correct Answer: D
Rationale: The correct answer is D: Disturbed thought processes. Echolalia, or the repetition of words, is indicative of disturbed thought processes, a common symptom in clients with schizophrenia. Choice A (Altered thought processes) is a more appropriate term than 'Disturbed thought processes' to describe the issue of echolalia. Choice B (Impaired social interaction) is not the best option in this scenario as echolalia is not primarily a social interaction issue. Choice C (Risk for self-directed violence) is not directly related to the symptom described in the question, which is echolalia, indicating a disturbance in thought processes.
In which condition is the 'butterfly rash' most commonly seen?
- A. Systemic lupus erythematosus
- B. Rheumatoid arthritis
- C. Psoriasis
- D. Dermatomyositis
Correct Answer: A
Rationale: The correct answer is A: Systemic lupus erythematosus (SLE). The 'butterfly rash' across the cheeks and nose is a classic sign of SLE, an autoimmune disease. This rash is a key dermatological manifestation of SLE, often triggered or worsened by exposure to sunlight. Choices B, C, and D are incorrect because the 'butterfly rash' is not commonly associated with rheumatoid arthritis, psoriasis, or dermatomyositis.
A male client with TB returns to the clinic for daily antibiotic injections for a urinary infection. The client has been taking anti-tubercular medications for 10 weeks and states he has ringing in his ears. Which prescribed medication should the PN report to the HCP?
- A. Pyridoxine with a B complex multivitamin
- B. Gentamicin 160 mg IM daily
- C. Rifampin 600 mg PO daily
- D. Isoniazid 300 mg PO daily
Correct Answer: B
Rationale: The correct answer is B: Gentamicin 160 mg IM daily. Gentamicin is an aminoglycoside antibiotic that can cause ototoxicity, leading to ringing in the ears (tinnitus). This symptom should be reported to the HCP immediately, as it may indicate a need to adjust or discontinue the medication. Choice A, Pyridoxine with a B complex multivitamin, is not the cause of ototoxicity. Choices C and D, Rifampin and Isoniazid, are anti-tubercular medications but are not associated with causing ringing in the ears.
A client on bedrest refuses to wear the prescribed pneumatic compression devices after surgery. Which action should the PN implement in response to the client's refusal?
- A. Emphasize the importance of active foot flexion
- B. Check the surgical dressing
- C. Complete an incident report
- D. Explain the use of an incentive spirometer every 2 hours
Correct Answer: A
Rationale: The correct action for the PN to implement when a client refuses pneumatic compression devices is to emphasize the importance of active foot flexion. Active foot flexion exercises can help prevent deep vein thrombosis (DVT) in clients who are not using the compression devices. Encouraging some form of circulation-promoting activity is crucial to reduce the risks associated with immobility. Checking the surgical dressing (Choice B) is important but not the immediate action to address the refusal of compression devices. Completing an incident report (Choice C) is not necessary in this situation as the client's refusal is not an incident. Explaining the use of an incentive spirometer (Choice D) is not directly related to addressing the refusal of compression devices for DVT prevention.