Nokea
When managing a physically assaultive client, the nurse's INITIAL priority is to
- A. Restrict the client to the room
- B. Place the client under one-to-one supervision
- C. Restore the client's self-control and prevent further loss of control
- D. Clear the immediate area of other clients to prevent harm
Correct Answer: C
Rationale: When dealing with a physically assaultive client, the initial priority is to focus on restoring the client's self-control and preventing further escalation. Restricting the client to the room (choice A) may escalate the situation and is not the initial priority. Placing the client under one-to-one supervision (choice B) is important but comes after ensuring the client's self-control. Clearing the immediate area of other clients (choice D) is essential for safety but is not the initial priority when compared to restoring the client's self-control.
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What are common risk factors for urinary tract infections (UTIs)?
- A. Poor hygiene and dehydration
- B. Increased sexual activity and pregnancy
- C. Use of urinary catheters and prolonged bed rest
- D. Family history and obesity
Correct Answer: A
Rationale: The correct answer is A: Poor hygiene and dehydration are common risk factors for urinary tract infections (UTIs). While choices B, C, and D may play a role in certain cases, poor hygiene and dehydration are more universally recognized as key factors contributing to UTIs. Increased sexual activity and pregnancy (choice B) can also increase the risk of UTIs, but they are not as universal as poor hygiene and dehydration. Choices C and D, the use of urinary catheters and prolonged bed rest, and family history and obesity, respectively, are risk factors for UTIs but are not as commonly associated as poor hygiene and dehydration.
A healthcare provider is caring for a client who has a leg fracture and reports severe pain. Which of the following actions should the healthcare provider take first?
- A. Administer pain medication
- B. Reposition the client's leg
- C. Elevate the client's leg
- D. Check the client's neurovascular status
Correct Answer: D
Rationale: Checking the client's neurovascular status is the priority when caring for a client with severe pain after a leg fracture. This assessment is crucial to identify any signs of vascular compromise or nerve damage, such as compartment syndrome. Administering pain medication can help alleviate the pain but should only be done after ensuring the client's neurovascular status is stable. Repositioning or elevating the leg may worsen the condition if there are underlying vascular issues, making these options lower in priority than assessing neurovascular status.
A client with a tracheostomy is exhibiting signs of respiratory distress. What is the first action the nurse should take?
- A. Increase the suction setting on the ventilator
- B. Suction the tracheostomy
- C. Notify the physician immediately
- D. Encourage deep breathing exercises
Correct Answer: B
Rationale: The correct first action for a client with a tracheostomy exhibiting signs of respiratory distress is to suction the tracheostomy. This helps clear the airway and improve breathing. Increasing the suction setting on the ventilator is not appropriate as the issue may be related to secretions that need to be directly removed. Notifying the physician should come after providing immediate nursing interventions. Encouraging deep breathing exercises is not suitable when the client is in respiratory distress and needs prompt intervention.
When caring for a client experiencing delirium, which of the following is essential?
- A. Controlling behavioral symptoms with low-dose psychotropics
- B. Identifying the underlying causative condition or illness
- C. Manipulating the environment to increase orientation
- D. Decreasing or discontinuing all previously prescribed medications
Correct Answer: B
Rationale: When caring for a client experiencing delirium, it is essential to identify the underlying causative condition or illness. Delirium can be caused by various factors such as infections, medication side effects, dehydration, or underlying health conditions. By identifying the root cause, appropriate treatment can be provided. Controlling behavioral symptoms with low-dose psychotropics (Choice A) may be considered in some cases but is not the primary essential step. Manipulating the environment to increase orientation (Choice C) can help manage symptoms but does not address the underlying cause. Decreasing or discontinuing all previously prescribed medications (Choice D) should only be done under medical supervision, as some medications may be necessary for the client's well-being.
A nurse is assisting with a presentation at a community center about personal disaster preparedness. Which of the following strategies should the nurse recommend for preparing a home disaster supply kit?
- A. Store enough water for 3 days
- B. Maintain communication with family
- C. Prepare only non-perishable food
- D. Prepare multiple escape routes
Correct Answer: A
Rationale: The correct answer is A: 'Store enough water for 3 days.' When preparing a home disaster supply kit, it is crucial to include enough water to last at least 3 days. This is because clean drinking water may not be readily available during a disaster situation. Choice B, 'Maintain communication with family,' is important for coordination but not directly related to preparing a supply kit. Choice C, 'Prepare only non-perishable food,' is also important but does not address the specific recommendation for water. Choice D, 'Prepare multiple escape routes,' is crucial for evacuation planning but does not pertain to the contents of a home disaster supply kit.