Nokea
Which teaching topics should the nurse cover before discharge? Select all that apply.
- A. Dietary restrictions
- B. Avoiding heavy lifting
- C. Staying out of bright sunlight
- D. Missed doses
- E. Bruising or blood in urine
- F. Need for frequent laboratory work
Correct Answer: A,D,E,F
Rationale: Warfarin requires dietary consistency, instructions on missed doses, monitoring for bleeding (bruising/blood in urine), and frequent INR checks.
You may also like to solve these questions
The client diagnosed with atrial fibrillation complains of numbness and tingling of her left arm and leg. The nurse assesses facial drooping on the left side and slight slurring of speech. Which nursing interventions should the nurse implement first?
- A. Schedule a STAT Magnetic Resonance Imaging of the brain.
- B. Call a Code STROKE.
- C. Notify the health-care provider (HCP).
- D. Have the client swallow a glass of water.
Correct Answer: B
Rationale: Symptoms suggest an acute stroke, requiring immediate activation of a Code STROKE (B) to expedite diagnosis and treatment. MRI (A), notifying HCP (C), and swallowing tests (D) follow protocol activation.
Which statement best describes the scientific rationale for alternating a nonnarcotic antipyretic and a nonsteroidal anti-inflammatory drug (NSAID) every two (2) hours to a female client diagnosed with bacterial meningitis?
- A. This regimen helps to decrease the purulent exudate surrounding the meninges.
- B. These medications will decrease intracranial pressure and brain metabolism.
- C. These medications will increase the client’s memory and orientation.
- D. This will help prevent a yeast infection secondary to antibiotic therapy.
Correct Answer: B
Rationale: Alternating antipyretics and NSAIDs (B) reduces fever and inflammation, lowering ICP and brain metabolism in meningitis. Exudate (A) is addressed by antibiotics, memory/orientation (C) is not directly affected, and yeast infections (D) are unrelated.
The nurse is caring for clients on the rehabilitation unit. Which clients should the nurse assess first after receiving the change-of-shift report?
- A. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs.
- B. The client with an L4 SCI who is crying and very upset about being discharged home.
- C. The client with an L2 SCI who is complaining of a headache and feeling very hot.
- D. The client with a T4 SCI who is unable to move the lower extremities.
Correct Answer: A
Rationale: Dyspnea and crackles in a C6 SCI patient (A) suggest respiratory compromise, a life-threatening condition requiring immediate assessment. Emotional distress (B), headache (C), or expected paralysis (D) are less urgent.
The nurse is assessing a client with a history of transient ischemic attacks (TIAs). Which finding is most concerning and should be reported immediately?
- A. Mild headache for 2 days
- B. Transient numbness in the left arm
- C. Slight dizziness when standing
- D. Occasional forgetfulness
Correct Answer: B
Rationale: Transient numbness in the left arm may indicate a TIA, which requires immediate reporting due to the risk of progression to a stroke.
The nurse is implementing interventions for the client who has increased ICP. The nurse knows that which result will occur if the increased ICP is left untreated?
- A. Displacement of brain tissue
- B. Increase in cerebral perfusion
- C. Increase in the serum pH level
- D. Leakage of cerebrospinal fluid
Correct Answer: A
Rationale: If untreated, increased ICP causes a shift in brain tissue and can result in irreversible brain damage and possibly death. ICP compresses structures within the cranium and leads to a decrease in cerebral perfusion, not increased perfusion. ICP compresses structures within the cranium and leads to acidosis; the pH level is decreased in acidosis. Leakage of CSF could occur if there were an opening in the subarachnoid space that could occur with trauma, but there is no indication that the increased ICP is due to trauma.