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Which of the following findings should the nurse expect?
- A. The client is oriented times three
- B. The client opens eyes to sound.
- C. The client is unable to obey commands.
- D. The client withdraws from pain
Correct Answer: A
Rationale: The correct answer is A: The client is oriented times three. This indicates that the client is alert and aware of person, place, and time. This finding is crucial in assessing the client's mental status and cognitive function. Opening eyes to sound (B) is a basic response but does not indicate orientation. Inability to obey commands (C) suggests altered mental status. Withdrawing from pain (D) may indicate a physical reflex rather than cognitive function. Overall, being oriented times three is the most comprehensive assessment of mental alertness and cognitive function.
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A nurse is preparing to feed a newly admitted client who has dysphagia. Which of the following actions should the nurse plan to take?
- A. Instruct the client to lift her chin when swallowing
- B. Talk with the client during her feeding.
- C. Sit at or below the client's eye level during feedings
- D. Discourage the client from coughing during feedings
Correct Answer: C
Rationale: The correct answer is C: Sit at or below the client's eye level during feedings. This is important for clients with dysphagia as it helps facilitate safe swallowing by promoting proper alignment of the head and neck. Sitting at or below the client's eye level reduces the risk of aspiration and choking during feeding. This position also allows the nurse to closely monitor the client for signs of difficulty swallowing.
Choice A is incorrect because instructing the client to lift her chin when swallowing can actually increase the risk of aspiration in individuals with dysphagia. Choice B is incorrect as talking with the client during feeding may distract them and increase the risk of swallowing difficulties. Choice D is incorrect because coughing is a protective mechanism that helps clear the airway, so discouraging coughing during feedings is not recommended for clients with dysphagia.
A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?
- A. \| can continue to take St John's wort while taking this medication
- B. I know It will be& couple of weeks before the medication helps me feel better
- C. I expect this medication to raise my blood pressure
- D. I should take this medication on an empty stomach
Correct Answer: B
Rationale: Correct Answer: B: "I know It will be a couple of weeks before the medication helps me feel better"
Rationale: Amitriptyline is a tricyclic antidepressant that can take several weeks to reach its full therapeutic effect. This statement shows the client understands the delayed onset of action of the medication, managing expectations. This is crucial in ensuring the client does not become discouraged if they do not feel immediate improvement.
Incorrect Choices:
A: "I can continue to take St John's wort while taking this medication" - St John's wort can interact with amitriptyline, leading to increased side effects and reduced effectiveness.
C: "I expect this medication to raise my blood pressure" - Amitriptyline can indeed cause hypotension, not hypertension.
D: "I should take this medication on an empty stomach" - Amitriptyline should be taken with food to reduce gastrointestinal side effects and improve absorption.
For each potential provider's prescription, click to specify if the potential prescription is anticipated or unanticipated for the client.
- A. Place client in supine position
- B. Limit fluid intake to 3,000 mL/day
- C. Administer oxytocin
- D. Maintain bed rest with bathroom privileges
- E. Administer betamethasone.
- F. Administer terbutaline.
Correct Answer: D,E,F
Rationale: [0, 0, 0, 1, 1, 1]
For the correct answer :
- D: Maintaining bed rest with bathroom privileges is anticipated as it helps in preventing physical strain while allowing essential movement.
- E: Administering betamethasone is anticipated for fetal lung maturation in preterm labor.
- F: Administering terbutaline is anticipated for delaying preterm labor by relaxing uterine muscles.
Other choices:
- A: Placing the client in a supine position is not anticipated as it can decrease blood flow to the fetus.
- B: Limiting fluid intake to 3,000 mL/day is not anticipated as hydration is vital during pregnancy.
- C: Administering oxytocin is not anticipated unless there is a specific indication for labor induction.
A nurse is reporting a client's laboratory tests to the provider to obtain a prescription for the cient's daily warfarin. Which of the following laboratory tests should the nurse plan to report to obtain the prescription for the warfarin?
- A. Fibrinogen level
- B. aPTT
- C. INR
- D. Platelet count
Correct Answer: C
Rationale: The correct answer is C: INR. The International Normalized Ratio (INR) is used to monitor and adjust the dosage of warfarin, an anticoagulant medication. A nurse needs to report the INR level to the provider to determine if the current dosage of warfarin is effective in preventing blood clots. A higher INR indicates a longer time it takes for blood to clot, meaning the warfarin dosage might need adjustment.
Incorrect choices:
A: Fibrinogen level - Fibrinogen is a protein involved in blood clotting but is not specific for monitoring warfarin therapy.
B: aPTT - Activated Partial Thromboplastin Time (aPTT) is used to monitor heparin therapy, not warfarin.
D: Platelet count - Platelet count measures the number of platelets in the blood and is not directly related to warfarin therapy.
Overall, the INR is the most
A nurse is performing postmortem care for a recently deceased client prior to the client's family visit. Which of the following actions should the nurse plan to take?
- A. Cross the client's arms across their chest.
- B. Hold the client's eyes shut for a few seconds
- C. Place the client in a high-Fowler's position
- D. Remove the client's dentures from their mouth.
Correct Answer: B
Rationale: The correct answer is B: Hold the client's eyes shut for a few seconds. This action is important to maintain a dignified appearance for the deceased client and to create a peaceful and respectful image for the family during their visit. Crossing the client's arms (A) or placing them in a high-Fowler's position (C) may not be necessary and can be considered unnecessary handling of the body. Removing the client's dentures (D) is not typically part of postmortem care unless specifically instructed. Holding the eyes shut briefly is a culturally sensitive and respectful practice that can help create a serene appearance for the family.