Nokea
When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?
- A. Grief work facilitation
- B. Vital signs monitoring
- C. Medication administration: skin
- D. Anxiety reduction
Correct Answer: A
Rationale: Grief work facilitation helps address body image disturbance in burn clients by supporting grief resolution related to altered appearance.
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A client is given an opiate drug for pain relief following general anesthesia. The client becomes extremely somnolent with respiratory depression. The physician is likely to order the administration of:
- A. naloxone (Narcan)
- B. labetalol (Normodyne)
- C. neostigmine (Prostigmin)
- D. thiothixene (Navane)
Correct Answer: A
Rationale: Naloxone reverses opioid-induced respiratory depression and somnolence by antagonizing opioid receptors. The other drugs do not address opioid overdose.
The nurse can promote relief of muscle pain, spasms, and tension by:
- A. having the client continue his activities as usual.
- B. immobilizing the client.
- C. applying heat, cold, pressure, or vibration to the painful area.
- D. giving as much pain medication as needed to ease the muscle.
Correct Answer: C
Rationale: Superficial heat and cold, massage, pressure, or vibration can be applied to alleviate pain associated with muscle tension, pain, or spasms.
A client is given an opiate drug for pain relief following general anesthesia. The client becomes extremely somnolent with respiratory depression. The physician is likely to order the administration of:
- A. naloxone (Narcan).
- B. labetalol (Normodyne).
- C. neostigmine (Prostigmin).
- D. thiothixene (Navane).
Correct Answer: A
Rationale: Naloxone is an opiate antagonist. It attaches to opiate receptors and blocks or reverses the action of narcotic analgesics. Choice 2 is incorrect because Labetalol is a beta blocker. Choice 3 is incorrect because Neostigmine is an anticholinesterase agent. Choice 4 is incorrect because Thiothixene is an antipsychotic agent.
A diet high in fiber content can help an individual to:
- A. lose body weight fast.
- B. reduce diabetic ketoacidosis.
- C. lower cholesterol.
- D. reduce the need for folate.
Correct Answer: C
Rationale: Fiber-rich foods (such as grains, apples, potatoes, and beans) can help lower cholesterol.
A patient is currently having a petit mal seizure in the clinic on the floor. Which of the following criteria has the highest priority in this situation?
- A. Provide a safe environment free of obstructions in the immediate area
- B. Call a code
- C. Contact the patient's physician
- D. Prevent excessive movement of the extremities
Correct Answer: A
Rationale: Patient safety should be the top concern about this patient.