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When a client expresses, 'I don't know how I will go on' while discussing feelings related to a recent loss, the nurse remains silent. What is the most likely reason for the nurse's behavior?
- A. The nurse is indicating disapproval of the statement.
- B. The nurse is showing respect for the client's loss.
- C. Silence is mirroring the client's sadness.
- D. Silence enables the client to contemplate what was expressed.
Correct Answer: D
Rationale: The correct answer is D because the nurse's silence allows the client to reflect on and process their emotions after expressing uncertainty about the future. By remaining silent, the nurse gives the client space to explore their feelings and thoughts without interruption. This can help the client gain insight and come to terms with their emotions.
A: The nurse's silence does not indicate disapproval, as it is a common therapeutic technique.
B: While the nurse may be showing respect for the client's loss, the primary reason for the silence is to facilitate the client's reflection.
C: Although silence can sometimes mirror the client's emotions, the main purpose here is to enable contemplation rather than direct mirroring.
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The client with a history of heart failure is taking furosemide (Lasix). Which laboratory result should the nurse monitor closely?
- A. Serum sodium.
- B. Serum potassium.
- C. Serum calcium.
- D. Serum magnesium.
Correct Answer: B
Rationale: The correct answer is B: Serum potassium. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Hypokalemia can exacerbate cardiac arrhythmias in patients with heart failure. Monitoring serum potassium levels is crucial to prevent complications.
Incorrect choices:
A: Serum sodium - Furosemide may cause hyponatremia, but it is less critical compared to hypokalemia in a client with heart failure.
C: Serum calcium - Furosemide does not directly affect calcium levels significantly in most cases.
D: Serum magnesium - While furosemide can cause hypomagnesemia, monitoring potassium is more essential in this scenario due to its impact on cardiac function.
A client with cirrhosis of the liver is being cared for by the healthcare team. Which clinical manifestation indicates that the client has developed hepatic encephalopathy?
- A. Asterixis.
- B. Jaundice.
- C. Ascites.
- D. Splenomegaly.
Correct Answer: A
Rationale: The correct answer is A: Asterixis. Hepatic encephalopathy is a neuropsychiatric syndrome associated with liver dysfunction. Asterixis, also known as liver flap, is a key clinical manifestation characterized by a flapping tremor of the hands when extended. This occurs due to impaired ammonia metabolism in the liver leading to neurotoxicity. Jaundice (B) is a sign of liver dysfunction but not specific to hepatic encephalopathy. Ascites (C) is the accumulation of fluid in the peritoneal cavity, common in liver cirrhosis but not indicative of hepatic encephalopathy. Splenomegaly (D) is enlargement of the spleen, which can occur in cirrhosis but is not a direct sign of hepatic encephalopathy.
A primipara at 38-weeks gestation is admitted to labor and delivery for a biophysical profile (BPP). The nurse should prepare the client for what procedures?
- A. Chorionic villus sampling under ultrasound.
- B. Amniocentesis and fetal monitoring.
- C. Ultrasonography and nonstress test.
- D. Oxytocin challenge test and fetal heart rate monitoring.
Correct Answer: C
Rationale: The correct answer is C: Ultrasonography and nonstress test. At 38 weeks gestation, a biophysical profile (BPP) is typically done to assess fetal well-being. Ultrasonography is used to evaluate fetal movements, tone, breathing movements, and amniotic fluid volume. The nonstress test assesses fetal heart rate in response to fetal movement, indicating fetal well-being. Chorionic villus sampling (A) and amniocentesis (B) are invasive procedures not typically done as part of a routine BPP. Oxytocin challenge test (D) is not indicated in this scenario as it is used to assess placental function in high-risk pregnancies.
A client from a nursing home is admitted with urinary sepsis and has a single-lumen, peripherally-inserted central catheter (PICC). Four medications are prescribed for 9:00 a.m. and the nurse is running behind schedule. Which medication should the nurse administer first?
- A. Piperacillin/tazobactam (Zosyn) in 100 ml D5W, IV over 30 minutes q8 hours.
- B. Vancomycin (Vancocin) 1 gm in 250 ml D5W, IV over 90 minutes q12 hours.
- C. Pantoprazole (Protonix) 40 mg PO daily.
- D. Enoxaparin (Lovenox) 40 mg subq q24 hours.
Correct Answer: A
Rationale: The correct answer is A: Piperacillin/tazobactam (Zosyn) in 100 ml D5W, IV over 30 minutes q8 hours. In a patient with urinary sepsis, timely administration of antibiotics is crucial to prevent further complications. Piperacillin/tazobactam is a broad-spectrum antibiotic effective against a wide range of bacteria commonly involved in sepsis. Administering it first ensures prompt initiation of treatment. Other choices (B) Vancomycin, (C) Pantoprazole, and (D) Enoxaparin are important medications but are not as time-sensitive in this scenario. Vancomycin and Enoxaparin have longer administration times, and Pantoprazole is a maintenance medication that is not urgent in the acute management of sepsis.
The client with chronic kidney disease (CKD) is receiving hemodialysis. Which finding should be reported to the healthcare provider immediately?
- A. Blood pressure of 150/90 mm Hg.
- B. Weight gain of 2 pounds since the last dialysis session.
- C. Blood glucose level of 120 mg/dl.
- D. Potassium level of 6.5 mEq/L.
Correct Answer: D
Rationale: The correct answer is D: Potassium level of 6.5 mEq/L. High potassium levels (hyperkalemia) in CKD patients receiving hemodialysis can lead to serious complications like cardiac arrhythmias or even cardiac arrest. Therefore, it is crucial to report this finding immediately to the healthcare provider for prompt intervention.
Explanation for other choices:
A: Blood pressure of 150/90 mm Hg - While elevated, this blood pressure reading is not an immediate concern unless accompanied by symptoms like chest pain or shortness of breath.
B: Weight gain of 2 pounds since the last dialysis session - While weight gain may indicate fluid retention, it is not an urgent issue unless it is rapid and significant.
C: Blood glucose level of 120 mg/dl - A blood glucose level of 120 mg/dl is within the normal range and does not require immediate action in this context.