Nokea
A postoperative client has returned to his room from the surgical recovery area. The client is sleeping, and the nurse notes that the client is disoriented when aroused.
Which of the following actions, if taken by the nurse, is BEST?
- A. Place the call bell within the client's reach.
- B. Stay with the client until he is totally oriented.
- C. Restrain all four extremities until the client is oriented.
- D. Elevate the side rails until the client is fully awake.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not the safety action (2) unnecessary to stay with the client, especially while he is sleeping (3) restraints are unnecessary at this time (4) correct-side rails should always be elevated for any disoriented client
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The nurse is caring for a client who had a subtotal thyroidectomy yesterday. Which of the following client statements would be of GREATest concern to the nurse?
- A. I have a sore throat when I swallow.
- B. My legs feel cramped and tingly.
- C. I feel like my heart is skipping beats.
- D. I feel sleepy all the time.
Correct Answer: B
Rationale: Muscle cramps and tingling in the legs post-thyroidectomy suggest hypocalcemia, a serious complication due to possible parathyroid gland damage, which regulates calcium. This requires immediate assessment and intervention. Options A, C, and D are less urgent: sore throat is expected, palpitations may indicate hyperthyroidism, and sleepiness is nonspecific.
The physician prescribes estrogen (Premarin) 0.625 mg daily for a 43-year-old woman. The nurse knows which of the following symptoms is a common initial side effect of this medication?
- A. Nausea.
- B. Visual disturbances.
- C. Tinnitus.
- D. Ataxia.
Correct Answer: A
Rationale: common at breakfast time; will subside after weeks of medication use; take after eating to reduce incidence
The geriatric residents of a long-term care facility are engaged in a reminiscing group. The nurse knows that the primary goal of this type of group activity is to
- A. provide psychosocial educational opportunities for stress and coping.
- B. provide an avenue for physical exercise.
- C. provide an environment for social interaction and companionship.
- D. reorient and provide a reality Test for confused clients.
Correct Answer: C
Rationale: primary goal of a reminiscing group for geriatric clients is to review and share their life experiences with the group members
A client in the ICU is given procainamide HCl (Pronestyl) slowly IV push.
- A. Which observation would prompt the nurse to withhold the next dose of procainamide?
- B. Presence of premature ventricular contractions.
- C. Occurrence of severe hypotension.
- D. Recurring paroxysmal atrial tachycardia.
- E. A sedimentation rate of 10.
Correct Answer: B
Rationale: Severe hypotension is a serious side effect of procainamide, requiring the dose to be withheld to prevent cardiovascular collapse. PVCs and atrial tachycardia are arrhythmias the drug treats, and a normal sedimentation rate is irrelevant.
Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies?
- A. Risk for injury
- B. Risk for knowledge deficit
- C. Altered thought process
- D. Disturbance in self-esteem
Correct Answer: A
Rationale: Risk for injury. Impaired judgment from substance abuse significantly increases the risk of accidents and injuries.