Nokea
Which of the following physician's orders would the nurse question on a client with chronic arterial insufficiency?
- A. Neurovascular checks every 2 hours
- B. Elevate legs on pillows
- C. Arteriogram in the morning
- D. No smoking
Correct Answer: B
Rationale: Neurovascular checks are a routine part of assessment with clients having this diagnosis. Elevation of the legs is contraindicated because it reduces blood flow to areas already compromised. Arteriogram is a routine diagnostic order. Smoking is highly correlated with this disorder.
You may also like to solve these questions
A nurse is taking a maternal history for a client at her first prenatal visit. Her pregnancy test was positive, she has two living children, she had one spontaneous abortion, and one infant died at the age of 3 months. Which of the following best describes the client at the present?
- A. Gravida 4, para 2, ab 1
- B. Gravida 5, para 3, ab 1
- C. Gravida 5, para 4, ab 0
- D. Gravida 4, para 3, ab 0
Correct Answer: B
Rationale: The client has been pregnant five times (current pregnancy, two living children, one spontaneous abortion, one infant death), delivered three children (two living, one died), and had one abortion.
A female client is anticipating a visit with her parents over the Thanksgiving holidays. She has recently begun experiencing periods of extreme shortness of breath, which her physician has labeled as panic attacks. Which of the following statements by the nurse would enhance therapeutic communication?
- A. Why do you feel this way?'
- B. Tell me about your dislike for your parents.'
- C. Don't worry, everything will be all right on your visit with your parents.'
- D. Perhaps you and I can discover what produces your anxiety.'
Correct Answer: D
Rationale: Asking the client to provide an explanation for her feelings is often intimidating. This response is probing and may make the client feel used and valued only for the information she can provide. This underrates the client's feelings and belittles her concerns. It may cause the client to stop sharing feelings for fear that they will be ridiculed. The emphasis is on working with the client. It shows that there is hope for change through collaboration.
An elective saline abortion has been performed on a 3-week primigravida. Following the procedure, the nurse should be alert for which early side effect?
- A. Water satiety
- B. Thirst
- C. Edema
- D. Diabetes insipidus
Correct Answer: B
Rationale: Saline absorption into the bloodstream increases serum sodium, leading to thirst as an early side effect.
A female client has just died. Her family is requesting that all nursing staff leave the room. The family's religious leader has arrived and is ready to conduct a ceremony for the deceased in the room, requesting that only family members be present. The nurse assigned to the client should perform the appropriate nursing action, which might include:
- A. Inform the family that it is the hospital's policy not to conduct religious ceremonies in client rooms.
- B. Refuse to leave the room because the client's body is entrusted in the nurse's care until it can be brought to the morgue.
- C. Tell the family that they may conduct their ceremony in the client's room; however, the nurse must attend.
- D. Respect the client's family's wishes.
Correct Answer: D
Rationale: It is rare that a hospital has a specific policy addressing this particular issue. If the statement is true, the nurse should show evidence of the policy to the family and suggest alternatives, such as the hospital chapel. Refusal to leave the room demonstrates a lack of understanding related to the family's need to grieve in their own manner. The nurse should leave the room and allow the family privacy in their grief. The family's wish to conduct a religious ceremony in the client's room is part of the grief process. The request is based on specific cultural and religious differences dictating social customs.
The primary focus of nursing interventions for the child experiencing sickle cell crisis is aimed toward:
- A. Maintaining an adequate level of hydration
- B. Providing pain relief
- C. Preventing infection
- D. O2 therapy
Correct Answer: A
Rationale: Maintaining the hydration level is the focus for nursing intervention because dehydration enhances the sickling process. Both oral and parenteral fluids are used. The pain is a result of the sickling process. Analgesics or narcotics will be used for symptom relief, but the underlying cause of the pain will be resolved with hydration. Serious bacterial infections may result owing to splenic dysfunction. This is true at all times, not just during the acute period of a crisis. O2 therapy is used for symptomatic relief of the hypoxia resulting from the sickling process. Hydration is the primary intervention to alleviate the dehydration that enhances the sickling process.