Nokea
Which of the following individuals is at the highest risk for suicide?
- A. 76-year-old widow with chronic renal failure
- B. 19-year-old with new SSRI therapy
- C. 28-year-old post-partum crying weekly
- D. 50-year-old client with obsessive-compulsive disorder (OCD) and depression
Correct Answer: A
Rationale: The correct answer is the 76-year-old widow with chronic renal failure. Elderly individuals with chronic diseases, especially men, are at very high risk for suicide. The other choices, although they may be vulnerable populations, do not carry as high a risk for suicide. The 19-year-old with new SSRI therapy may actually have a lower risk as they are receiving treatment. The 28-year-old post-partum individual is experiencing a common emotional response after childbirth, which is not necessarily indicative of a high suicide risk. The 50-year-old with OCD and depression is at risk but not as high as elderly individuals with chronic illness.
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To determine the standards of care for the institution, the nurse should consult?
- A. Organizational Chart
- B. Personnel policies
- C. Policies and procedure manual
- D. Job descriptions
Correct Answer: C
Rationale: The correct answer is the 'Policies and procedure manual.' This manual outlines the policies and procedures that govern patient care within the institution, including the standards of care that healthcare providers are expected to follow. Consulting the policies and procedure manual ensures that the nurse is adhering to the established guidelines and protocols. Choices A, B, and D are incorrect because although they are important documents within an institution, they do not specifically define the standards of care for patient management. The organizational chart illustrates the hierarchy of the institution, personnel policies outline rules related to employees, and job descriptions detail specific roles and responsibilities, none of which directly define patient care standards.
Which behavior by a new nurse would indicate to the charge nurse that this nurse is following standard precautions?
- A. Wearing clean gloves while performing a heel stick on an infant
- B. Wearing the same gloves for assessments of clients in the same room
- C. Wearing sterile gloves when changing the urine bag and nasogastric canister of an infected client
- D. Donning a gown when responding to a request by the family to check the IV pump on a client with rotavirus
Correct Answer: A
Rationale: The correct answer is wearing clean gloves while performing a heel stick on an infant. Standard precautions require the use of gloves when there is a risk of exposure to blood or body fluids. Clean gloves are suitable for this task as they provide adequate protection without being sterile. Choice B is incorrect because wearing the same gloves for different clients can lead to cross-contamination, violating standard precautions. Choice C is incorrect as sterile gloves are usually not required for changing a urine bag and nasogastric canister unless a specific aseptic technique is indicated; standard precautions do not demand sterile gloves for such tasks. Choice D is incorrect as donning a gown is not necessary for checking an IV pump unless there is a risk of exposure to bodily fluids that would necessitate full-body protection, which is not indicated in this scenario.
During the admission assessment for a client undergoing breast augmentation, which information should the nurse prioritize reporting to the surgeon before surgery?
- A. The client is concerned about who will care for her two children while she recovers.
- B. The client has a history of postoperative dehiscence after a previous C-section.
- C. The client's statement that her last menstrual period was 8 weeks prior.
- D. The client's concerns over pain control postoperatively.
Correct Answer: C
Rationale: The most important information for the nurse to report to the surgeon before surgery is the client's statement that her last menstrual period was 8 weeks prior. This information is crucial as the client may be pregnant, and a pregnancy test will need to be completed before administering any anesthetic agents. Reporting this detail ensures patient safety and prevents potential risks associated with anesthesia. Choices A, B, and D are important aspects of care but do not take precedence over the need to rule out pregnancy before surgery.
One day postoperative, the client complains of dyspnea, and his respiratory rate (RR) is 35, slightly labored, and there are no breath sounds in the lower-right base. The nurse should suspect:
- A. cor pulmonale.
- B. atelectasis.
- C. pulmonary embolism.
- D. cardiac tamponade.
Correct Answer: B
Rationale: The correct answer is atelectasis. The absence of breath sounds in the lower-right base is a key finding in atelectasis, which occurs when a portion of the lung collapses. The other symptoms such as dyspnea and increased respiratory rate could be present in various pulmonary conditions. Cor pulmonale is typically associated with chronic lung disease, pulmonary embolism presents with sudden onset dyspnea and chest pain, and cardiac tamponade manifests with Beck's triad of hypotension, distended neck veins, and muffled heart sounds.
A patient has recently been prescribed Lidocaine Hydrochloride. Which of the following symptoms may occur with an overdose?
- A. Memory loss and lack of appetite
- B. Confusion and fatigue
- C. Heightened reflexes
- D. Tinnitus and spasticity
Correct Answer: B
Rationale: The correct answer is 'Confusion and fatigue.' Lidocaine Hydrochloride, when taken in excess, can lead to symptoms such as confusion and fatigue. It affects the central nervous system, leading to these cognitive and physical impairments. Choice A ('Memory loss and lack of appetite') is incorrect because memory loss is not a common symptom of Lidocaine Hydrochloride overdose, and lack of appetite is not a typical effect. Choice C ('Heightened reflexes') is incorrect as Lidocaine Hydrochloride overdose usually depresses reflexes rather than heightening them. Choice D ('Tinnitus and spasticity') is incorrect as tinnitus and spasticity are not commonly associated with Lidocaine Hydrochloride overdose.