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What should be the nurse's first action when caring for a client with a traumatic amputation?
- A. Apply pressure and elevate the limb
- B. Stop the bleeding and control shock
- C. Place the client in a Trendelenburg position
- D. Place the client in a sitting position
Correct Answer: A
Rationale: The correct first action is A: Apply pressure and elevate the limb. This is because applying pressure helps control bleeding and elevating the limb reduces blood flow to the area, minimizing further blood loss. This immediate intervention is crucial in managing the traumatic amputation and preventing complications.
Summary of why other choices are incorrect:
B: Stopping bleeding and controlling shock can be important but not the first action.
C: Placing the client in a Trendelenburg position (feet elevated higher than the head) is contraindicated in cases of traumatic amputation as it can increase bleeding.
D: Placing the client in a sitting position is not appropriate as it can worsen bleeding and lead to further complications.
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Which of the following statements about the mental health examination is true?
- A. A patient's family is the best resource for information about the patient's coping skills.
- B. It is usually sufficient to gather mental health information during the health history interview.
- C. It takes an enormous amount of extra time to integrate the mental health examination into the health history interview.
- D. It is usually necessary to perform a complete mental health examination to get a good idea of the patient's level of functioning.
Correct Answer: B
Rationale: The correct answer is B because the mental health examination should be integrated into the health history interview. This allows for a comprehensive understanding of the patient's mental health status. Gathering mental health information during the health history interview is crucial as it provides insight into the patient's current mental state, past history, and potential risk factors. This integrated approach is efficient and effective in assessing the patient's mental health needs.
A is incorrect because while family input can be valuable, it is not always the best or only resource for information about coping skills.
C is incorrect as integrating the mental health examination into the health history interview should not necessarily take an enormous amount of extra time if done efficiently.
D is incorrect as a complete mental health examination may not always be necessary to assess the patient's level of functioning; integrating mental health information into the health history interview can often provide sufficient insight.
A nurse is teaching a patient with diabetes about managing blood glucose levels. Which of the following statements by the patient indicates the need for further education?
- A. I will monitor my blood glucose levels regularly.
- B. I will exercise regularly to help manage my condition.
- C. I will stop taking my insulin once my blood glucose is normal.
- D. I will eat a balanced diet and avoid sugary foods.
Correct Answer: C
Rationale: The correct answer is C. Stopping insulin once blood glucose is normal is incorrect as insulin is crucial for managing diabetes even when blood glucose levels are within the target range. Insulin helps regulate blood sugar levels consistently, and stopping it abruptly can lead to hyperglycemia. Choices A, B, and D are correct statements indicating good diabetes management practices. Monitoring blood glucose levels, exercising regularly, and following a balanced diet are essential for controlling blood sugar levels and overall health.
A nurse is caring for a patient with chronic kidney disease (CKD). Which of the following lab results would the nurse expect to be elevated in this patient?
- A. Blood urea nitrogen (BUN).
- B. Calcium.
- C. Potassium.
- D. Sodium.
Correct Answer: A
Rationale: The correct answer is A: Blood urea nitrogen (BUN). In CKD, the kidneys are unable to effectively filter waste products, leading to an increase in BUN levels. Elevated BUN indicates impaired kidney function. Calcium, potassium, and sodium levels may also be affected in CKD, but they are more likely to be imbalanced rather than consistently elevated. Calcium levels may be low due to impaired vitamin D activation, potassium levels may be high due to decreased excretion, and sodium levels can fluctuate based on fluid status. Therefore, while these lab values may be abnormal in CKD, BUN is the most consistently elevated marker of kidney dysfunction.
What is the most important assessment for a client who has been receiving chemotherapy for several weeks?
- A. Check for signs of infection
- B. Monitor the client's weight
- C. Monitor the client's nutrition
- D. Check for skin changes
Correct Answer: A
Rationale: The correct answer is A: Check for signs of infection. This is crucial because chemotherapy weakens the immune system, increasing the risk of infections. Signs of infection such as fever, chills, sore throat, and cough should be closely monitored to prevent serious complications. Monitoring weight (B) and nutrition (C) are important but not as critical as detecting infections promptly. Checking for skin changes (D) is also important, but it is secondary to identifying and managing infections due to the immediate threat they pose to the client's health.
What is the most effective action for a client with suspected sepsis?
- A. Administer antibiotics
- B. Administer fluids
- C. Administer fluids
- D. Administer oxygen
Correct Answer: A
Rationale: The correct answer is A: Administer antibiotics. Antibiotics are crucial in treating sepsis as they help to fight the underlying infection causing the condition. Administering antibiotics promptly can prevent the infection from spreading and worsening. Fluids (choices B and C) are important for treating sepsis to maintain blood pressure and support organ function, but antibiotics are the primary intervention to target the infection. Administering oxygen (choice D) may be necessary to support respiratory function in septic patients, but it is not the most effective action to address the underlying infection.