Nokea
The nurse is caring for clients on a psychiatric unit and is suddenly faced with multiple issues.
Which of the following situations require the nurse's IMMEDIATE attention?
- A. A client with bipolar disorder walks into the dayroom in her underwear and begins dancing.
- B. A client with depression says to the nurse, 'My plan is complete, and I'm ready to go for it.'
- C. A client recovering from substance abuse says to the nurse, 'My plan is complete, and I'm ready to go for it.'
- D. A client with schizophrenia tells the nurse that it's 'God's will' that he destroy the 'evil TV'.
Correct Answer: B
Rationale: Strategy: 'Require IMMEDIATE intervention' indicates that you are looking for the least stable situation. (1) should remove to quiet area, decrease environmental stimuli (2) correct-could indicate impending suicide, requires immediate follow-up (3) potential suicide is more immediate concern (4) command hallucination, potential suicide takes priority
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During the rehabilitative phase, the client's burns become infected with pseudomonas. The topical dressing most likely to be ordered for the client is:
- A. Silver sulfadiazine (Silvadene)
- B. Poviodine (Betadine)
- C. Mafenide acetate (Sulfamylon)
- D. Silver nitrate
Correct Answer: C
Rationale: Mafenide acetate (Sulfamylon) is particularly effective against Pseudomonas infections due to its broad-spectrum antibacterial activity and ability to penetrate eschar. Silver sulfadiazine is less effective against Pseudomonas, and povidone-iodine and silver nitrate are not the primary choices for Pseudomonas infections. Answers A, B, and D are incorrect because they are less effective for this specific infection.
An adult has received an injection of immunoglobulin. The client asks what this injection will do for him. The nurse's reply includes the information that he will develop which type of immunity as a result of this injection?
- A. Active natural immunity
- B. Active artificial immunity
- C. Passive natural immunity
- D. Passive artificial immunity
Correct Answer: D
Rationale: Immunoglobulin provides preformed antibodies, conferring passive artificial immunity. Active immunity requires the body to produce antibodies, and natural immunity involves natural exposure.
A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure
- A. right heart function
- B. left heart function
- C. renal tubule function
- D. carotid artery function
Correct Answer: B
Rationale: left heart function. The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. It can provide hemodynamic information such as intracardiac pressure readings and oxygen saturation data, and even transvenous pacing. Information about left ventricular function is important because it directly affects tissue perfusion. Right-sided heart function is assessed through the evaluation of the central venous pressure (CVP).
The nurse is providing instructions for a client with pneumonia. What is the most important information to convey to the client?
- A. Take at least 2 weeks off from work.
- B. You will need another chest x-ray in 6 weeks.
- C. Take a longer temperature range of time.
- D. Complete all of the antibiotic even if your findings decrease.
Correct Answer: D
Rationale: Complete all of the antibiotic even if your findings decrease. Finishing the full antibiotic course prevents recurrence and resistance.
The nurse is caring for a client who is postoperative day 1 after a laparoscopic cholecystectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Right shoulder pain.
- D. Urine output of 40 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-cholecystectomy requiring immediate evaluation. Options B, C, and D are expected: incision pain is normal, shoulder pain is from referred diaphragmatic irritation, and urine output 40 mL/hour is adequate.