Nokea
What is the highest priority for post ECT care?
- A. Observe for confusion
- B. Monitor respiratory status
- C. Reorient to time, place, and person
- D. Document the client's response to the treatment
Correct Answer: B
Rationale: The highest priority for post ECT care is to monitor respiratory status. This is crucial because a life-threatening side effect of ECT is respiratory arrest. While observing for confusion and reorienting the client are important aspects of post ECT care, they are not as critical as ensuring the client's respiratory status is stable. Documenting the client's response to treatment is also important for maintaining accurate medical records, but it is not the highest priority immediately post ECT.
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The nurse is providing disease prevention education to a 63-year-old woman with a negative family history of breast cancer. The nurse recommends the patient schedule mammograms with which frequency?
- A. Every 5 years
- B. Every 10 years
- C. Every other year
- D. Once a year
Correct Answer: C
Rationale: Mammograms, along with breast self-examinations and other routine tests, are key for the early diagnosis and treatment of breast cancer. All major societies (WHO, ACS, USPSTF) recommend a screening mammogram every two years in women of this age at average risk of breast cancer. The recommended frequency may change if there are identified family history and significant risk factors. Choosing 'Once a year' is too frequent and not aligned with current guidelines. Opting for 'Every 5 years' or 'Every 10 years' intervals is not adequate for regular breast cancer screening and may increase the risk of cancer progression. Therefore, 'Every other year' is the most appropriate choice for this patient without a family history of breast cancer.
What does an anti-kickback statute prevent?
- A. It prevents healthcare workers from providing food or hosting parties to celebrate special occasions at work.
- B. It promotes thorough and complete documentation when a client becomes injured.
- C. It forbids giving or accepting gifts to promote or provide referrals for certain services.
- D. It prevents physicians from ordering treatments that may require nursing care beyond the usual amount.
Correct Answer: C
Rationale: An anti-kickback statute aims to prevent healthcare providers, clients, consultants, or related organizations from giving or accepting gifts to reward others for referrals of certain services. Choice A is incorrect because providing food or hosting parties at work is not the primary focus of anti-kickback statutes. Choice B is incorrect as it pertains more to documentation practices rather than gift-giving. Choice D is incorrect as it refers to the scope of physician orders and nursing care, not gift exchanges for referrals. The correct answer, as stated, aligns with the purpose of anti-kickback statutes to prevent improper incentives in healthcare relationships.
You have noticed that the last several patients you have cared for have had questionable blood pressure readings from their arterial lines. When checked against cuff pressures, a discrepancy has been noted, and further investigation has revealed faulty transducers. This is not the first product issue with this company. What positive step could you take to help resolve this situation?
- A. Use the old stock from a previous company
- B. Verify the cuff pressures every hour to ensure accuracy
- C. Notify the risk manager
- D. Form a peer workgroup to evaluate new products
Correct Answer: D
Rationale: Forming a peer workgroup to evaluate new products would be an excellent opportunity for collaboration among peers, management, and the purchasing department. When clinicians are engaged to work toward solutions that address patient care issues, they experience more empowerment and control over their work environments.
Choice A is incorrect because using old stock from a previous company does not address the root cause of the faulty transducers from the current company. Choice B is incorrect as verifying cuff pressures every hour does not directly address the issue of faulty transducers. Choice C is less effective than forming a peer workgroup as it involves only notifying the risk manager without involving a collaborative effort to resolve the product issue.
Gio told his nurse that the FBI is monitoring and recording his every movement and that microphones have been placed in the unit walls. Which action would be the most therapeutic response?
- A. Confront the delusional material directly by telling Gio that this simply is not so.
- B. Tell Gio that this must seem frightening to him but that you believe he is safe here.
- C. Tell Gio to wait and talk about these beliefs in his one-on-one counseling sessions.
- D. Isolate Gio when he begins to talk about these beliefs.
Correct Answer: B
Rationale: The most therapeutic response in this situation is to acknowledge Gio's feelings of fear and validate his experience by expressing empathy ('this must seem frightening to him'). By reassuring Gio that he is safe in the current environment, the nurse can help reduce his anxiety and build trust. Choice A is not recommended as directly confronting delusional beliefs may lead to increased distress and resistance. Choice C delays addressing Gio's concerns and may not provide immediate support. Choice D of isolating Gio can worsen his feelings of paranoia and distrust in the treatment setting.
A client with schizophrenia seems to stop focusing during a conversation with a nurse and begins looking at the ceiling and talking to themselves. Which of the following actions should the nurse take?
- A. Stop the interview at this point and resume later when the client is better able to concentrate
- B. Ask the client, 'Are you seeing something on the ceiling?'
- C. Tell the client, 'You seem to be looking at something on the ceiling. I see something there, too.'
- D. Continue the interview without commenting on the client's behavior
Correct Answer: B
Rationale: When a client with schizophrenia experiences a break in reality like staring at the ceiling and talking to themselves, the nurse should ask directly about the hallucination, as stated in choice B. By doing so, the nurse can assess the situation, identify the client's needs, and evaluate any potential risk for injury. Choices A, C, and D are incorrect. Stopping the interview (choice A) may not address the immediate concern of the hallucination. Providing false reassurance (choice C) or ignoring the behavior (choice D) does not actively address the client's altered perception of reality.