Nokea
Which situations would prompt the health care team to use the client’s advance directive to make a decision regarding care? Select all that apply.
- A. Client diagnosed with lumbar spinal cord compression has paraplegia
- B. Client’s Glasgow Coma Scale (GCS) score is 3
- C. Client is refusing a life-saving treatment due to religious beliefs
- D. Client with intracerebral hemorrhage has aphasia
- E. Oriented client has cancer and is on a ventilator
Correct Answer: B,D
Rationale: Advance directives guide care when clients cannot communicate decisions, as with a GCS of 3 (unconscious) or aphasia from hemorrhage. Paraplegia, religious refusal, and ventilator use in an oriented client do not impair decision-making capacity.
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The women’s health nurse is caring for a 30-year-old client who wants to use the ethinyl estradiol and norelgestromin patch for contraception. Regarding this method of birth control, which finding should be most concerning to the nurse?
- A. Client reports heavy menstrual cycles
- B. History of breast cancer in maternal aunt
- C. History of deep venous thrombosis
- D. Weight is 186 lb (84.4 kg) and BMI is 31.0 kg/m^2
Correct Answer: C
Rationale: Deep venous thrombosis is a contraindication for estrogen-containing contraceptives like the patch due to increased clotting risk. Heavy menses, family history of breast cancer, and obesity are less critical.
The nurse is caring for an elderly woman who had surgery on her right foot yesterday. The woman had a broken left arm three months ago and has osteoarthritis. Which type of assistive device will probably be most appropriate for this client?
- A. Quad cane
- B. Crutches
- C. Walker
- D. Tripod cane
Correct Answer: C
Rationale: A walker provides maximum stability for an elderly woman with recent foot surgery, prior arm injury, and osteoarthritis, ensuring safe ambulation.
The nurse is talking to a client with a newly diagnosed seizure disorder who has a prescription for levetiracetam. Which of the following statements by the client would require follow-up?
- A. I can begin driving my car again after I have been taking this medication for 2 weeks
- B. I need to contact my health care provider if I develop a rash while taking this medication
- C. I should report any new or increased anxiety I experience while taking this medication
- D. I understand that drowsiness is an adverse effect of this medication that may improve over time.
Correct Answer: A
Rationale: Driving restrictions for seizure disorders typically last 6-12 months seizure-free, not 2 weeks, posing a safety risk. Reporting rashes and anxiety are correct due to potential side effects of levetiracetam.
A nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD) and a history of type 2 diabetes mellitus requiring insulin. The client has been prescribed prednisone. The nurse anticipates which need?
- A. Close monitoring for hypotension
- B. Gradually increasing the prednisone dose
- C. Increasing the insulin dose
- D. Monitoring and recording intake and output
Correct Answer: C
Rationale: Prednisone increases blood glucose, necessitating a higher insulin dose in diabetes. Hypotension is not a primary concern, prednisone is not typically titrated upward, and intake/output monitoring is less critical.
A client with cancer of the stomach has a gastric resection. The nurse should tell the client that following surgery:
- A. He can eat any type food he wants to eat.
- B. Proteins and vitamins will assist with healing.
- C. He will only be able to have high-calorie liquids.
- D. Increasing his fat intake will help promote healing.
Correct Answer: B
Rationale: Proteins and vitamins support tissue repair post-gastrectomy. Any food may cause dumping syndrome. High-calorie liquids are too restrictive. High fat delays gastric emptying.