Nokea
Which of the following actions should the nurse plan to take?
- A. Apply a cold compress to the site.
- B. Elevate the affected arm above heart level.
- C. Place a warm, moist compress on the site.
- D. Massage the area to reduce inflammation.
Correct Answer: B
Rationale: The correct answer is B: Elevate the affected arm above heart level. Elevating the affected arm helps reduce swelling and promote circulation, aiding in the healing process. By elevating the arm above heart level, the nurse can assist in reducing inflammation and preventing further complications. Applying a cold compress (choice A) can be helpful for acute injuries, but it may not be the most appropriate initial action. Placing a warm, moist compress (choice C) can potentially worsen swelling in this case. Massaging the area (choice D) could aggravate the injury and increase inflammation.
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Which finding should the nurse identify as an indication that the medication is effective?
- A. Heart rate 140/min
- B. Capillary refill 3 seconds
- C. Cessation of nocturnal enuresis
- D. Absence of hypoglycemic episodes
Correct Answer: C
Rationale: The correct answer is C: Cessation of nocturnal enuresis. This indicates the medication is effective because it shows improvement in the condition being treated, which in this case is nocturnal enuresis. Nocturnal enuresis is the involuntary passage of urine during sleep and it can be a result of various factors such as hormonal imbalance or bladder control issues. Therefore, if the medication is effective, it should lead to the cessation of this symptom.
Heart rate (A) and capillary refill (B) are not necessarily indicators of the effectiveness of the medication in treating nocturnal enuresis. Absence of hypoglycemic episodes (D) is more related to diabetes management rather than nocturnal enuresis.
The nurse should intervene and explain to the AP that this statement constitutes which of the following torts?
- A. Assault
- B. Battery
- C. False imprisonment
- D. Negligence
Correct Answer: A
Rationale: The correct answer is A: Assault. Assault is the intentional act causing the apprehension of harmful or offensive contact. In this scenario, the statement made by the AP creates fear or apprehension of harm, even though no physical contact has occurred yet.
Choice B (Battery) involves actual physical contact, which is not present here. Choice C (False imprisonment) involves restricting someone's movement, not applicable in this situation. Choice D (Negligence) is the failure to exercise reasonable care, which is not the case here. The correct answer, assault, best fits the scenario described.
Which of the following actions should the nurse include in the plan of care?
- A. Encourage physical activity prior to bedtime
- B. Replace the carpet with hardwood floors
- C. Wear clothing with zippers instead of buttons
- D. Place locks at the top of exterior doors
Correct Answer: D
Rationale: The correct answer is D: Place locks at the top of exterior doors. This action is crucial in ensuring the safety and security of the individual, especially in cases where the person may be at risk of wandering or elopement. Placing locks at the top of exterior doors can prevent the individual from leaving the house unsupervised, which is essential for their safety. Encouraging physical activity prior to bedtime (A) may disrupt sleep patterns. Replacing carpet with hardwood floors (B) is not directly related to the safety of the individual. Wearing clothing with zippers instead of buttons (C) may be a personal preference but does not address safety concerns.
Which complication should the nurse monitor for?
- A. Contractions
- B. Increased fetal movement
- C. Hypertension
- D. Hypoglycemia
Correct Answer: A
Rationale: The correct answer is A: Contractions. Nurses should monitor for contractions as they could indicate preterm labor or other complications. Increased fetal movement (B) is not necessarily a complication but could be a sign of fetal well-being. Hypertension (C) is important to monitor but may not be directly related to the current situation. Hypoglycemia (D) is also important but not typically a primary concern in this situation.
Which of the following findings should the nurse report to the provider?
- A. Abdominal pain
- B. Belching
- C. Fatulence
- D. Sore throat
Correct Answer: A
Rationale: The correct answer is A: Abdominal pain. Abdominal pain is a significant finding that could indicate underlying health issues and requires immediate attention from the provider for further assessment and intervention. Belching and flatulence are common gastrointestinal symptoms that may not necessarily warrant immediate reporting. Sore throat, unless severe or persistent, can often be managed with over-the-counter remedies. It is important to prioritize reporting symptoms that could be indicative of serious conditions to ensure timely and appropriate care.