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Which of the following actions should the nurse Include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
- A. Use a face shield with a mask when providing care to the client.
- B. Tell the client.You seem to be very upset.""
- C. Engage the panic alarm:
- D. Initiate seclusion protocol
Correct Answer: B
Rationale: The correct answer is B because acknowledging the client's emotions can help de-escalate the situation. By stating, "You seem to be very upset," the nurse shows empathy and understanding, which can help the client feel heard and validated. Using a face shield, engaging the panic alarm, or initiating seclusion protocol are not appropriate actions in this scenario as they do not address the client's emotional state or help in calming them down. Face shield and panic alarm are more related to safety precautions, while seclusion protocol should only be considered as a last resort for safety reasons. Therefore, choice B is the most appropriate action for interacting with a client who is aggravated, pacing, and speaking loudly.
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Which of the following actions should the nurse take first?
- A. Determine the client's Glasgow Coma Scale score
- B. Insert an indwelling urinary catheter for the client.
- C. Administer mannitol IV bolus to the client
- D. Prepare the client for an MRI of the brain.
Correct Answer: A
Rationale: The correct answer is A: Determine the client's Glasgow Coma Scale (GCS) score. This is the priority action as it helps assess the client's level of consciousness and neurological status quickly. It guides further interventions and treatment decisions. Inserting an indwelling urinary catheter (B) or administering mannitol IV bolus (C) may be needed but assessing neurological status comes first. Preparing for an MRI (D) is important but not the initial step.
To prevent a compromise in placental blood flow during the intraoperative period, which of the following actions should the nurse take?
- A. Position the client in reverse Trendelenburg
- B. Place a wedge under one of the client's hips.
- C. Assist the client into the lithotomy position.
- D. Insert a pillow under the clients frees
Correct Answer: B
Rationale: Hip wedges optimize maternal blood flow.
Which of the following manifestations should the nurse expect?
- A. Drooling
- B. Malaise
- C. Tinnitus
- D. Rhinorrhea
Correct Answer: B
Rationale: The correct answer is B: Malaise. Malaise is a general feeling of discomfort or unease, commonly seen in various health conditions. In this scenario, malaise can be an expected manifestation due to its non-specific nature and association with underlying illnesses. Drooling (A), tinnitus (C), and rhinorrhea (D) are not typically associated with the given context and are less likely to be expected manifestations.
When performing medication reconciliation for the client, which of the following actions should the nurse take?
- A. Encourage the client to make his own list after he returns to his home
- B. Include any adverse effects of the medications the client might develop
- C. Exclude nutritional supplements from the list of medications the client reports
- D. Compare new prescriptions with the fist of medications the client reports,
Correct Answer: D
Rationale: Comparing prescriptions prevents duplication and interactions.
Which of the following findings should the nurse include in the teaching?
- A. Swelling of the face
- B. Bleeding gums
- C. Urinary frequency
- D. Faintness upon rising
Correct Answer: A
Rationale: Facial swelling may indicate preeclampsia requiring prompt evaluation.