Nokea
When teaching a group of clients about emergency care for a snake bite, which of the following information should the nurse include?
- A. Raise the affected extremity above the level of the heart.
- B. Immobilize the affected extremity with a splint
- C. Apply ice to the bite area
- D. Apply a tourniquet to the affected extremity.
Correct Answer: B
Rationale: The correct answer is B: Immobilize the affected extremity with a splint. This is important to prevent the spread of venom through the lymphatic system. Elevating the extremity (A) can increase the spread of venom. Applying ice (C) can constrict blood vessels, trapping venom in the area. Applying a tourniquet (D) can lead to tissue damage and worsen the condition. Immobilizing with a splint is the most effective way to limit movement and venom spread.
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The medical-surgical nurse, who cares for a patient newly diagnosed with cancer, observes the patient becoming angry with the physicians and nursing staff. The best approach to diffuse the emotionally charged discussion is to
- A. allow the patient and family members time to be alone.
- B. arrange time for the patient to speak with another patient with cancer.
- C. direct the discussion and validation of emotion, without false reassurance.
- D. request a consultation from a social worker on the oncology unit.
Correct Answer: C
Rationale: Validating emotions without dismissing them helps the patient process feelings.
If a client denies having a hearing impairment, which question would encourage them to respond?
- A. Do you always ask people to repeat questions? If so, do you think that you have a hearing problem?
- B. Are you cupping your ear for a reason? Do you have trouble hearing?
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Asking open-ended questions increases the likelihood of acknowledgment and discussion of the issue.
To prevent a common, adverse effect of prolonged use of phenytoin sodium (Dilantin), patients taking the drug are instructed to
- A. avoid crowds and obtain an annual influenza vaccination.
- B. drink at least 2 L of fluids daily, including 8 to 10 glasses of water.
- C. eat a potassium-rich, low-sodium diet.
- D. practice good dental hygiene and report gum swelling or bleeding.
Correct Answer: D
Rationale: Phenytoin can cause gum hyperplasia, so good dental hygiene is essential.
What physical manifestations would cue you that your client is experiencing an escalating level of anxiety?
- A. High blood pressure
- B. Increased heart rate
- C. Decreased oxygen supply
- D. Muscle relaxation
Correct Answer: D
Rationale: The correct answer is D because it is the most appropriate response based on physiological and medical principles.
Before giving a beta-adrenergic blocker glaucoma agent, you would notify the physician if the client discloses a history of what condition?
- A. Hypertension
- B. Tachycardia
- C. Rheumatoid arthritis
- D. Bradycardia
Correct Answer: D
Rationale: Beta-adrenergic blockers can exacerbate bradycardia, so the physician should be notified before administration.