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While caring for a client who is postoperative and has refused to use an incentive spirometer following major abdominal surgery, what is the nurse's priority action?
- A. Request that a respiratory therapist discuss the technique for using the incentive spirometer
- B. Determine the reasons why the client is refusing to use the incentive spirometer
- C. Document the client's refusal to participate in health restorative activities
- D. Administer a pain medication to the client
Correct Answer: B
Rationale: The nurse's priority is to determine the reasons why the client is refusing to use the incentive spirometer. By understanding the client's concerns or barriers, the nurse can address them appropriately. Requesting a respiratory therapist (Choice A) may be necessary later but is not the priority. Documenting the refusal (Choice C) is important but does not address the immediate need to assess and intervene. Administering pain medication (Choice D) without addressing the root cause of refusal is not appropriate and may mask the issue rather than resolve it.
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A client with type 1 diabetes mellitus is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?
- A. Ask, 'Tell me what I can do to help you overcome your fear of giving yourself injections.'
- B. Instruct, 'You need to learn how to give yourself insulin injections immediately.'
- C. State, 'Insulin injections are important for managing your diabetes, so you must learn them.'
- D. Mention, 'Many people with diabetes manage well with insulin injections.'
Correct Answer: A
Rationale: The correct answer is A. Asking the client what can be done to help overcome the fear of self-injections demonstrates empathy, understanding, and a willingness to support the client in addressing their barriers. This approach facilitates open communication, acknowledges the client's feelings, and involves them in the decision-making process. Choices B and C are authoritarian and may increase resistance in the client by being directive and not considering the client's perspective. Choice D, while positive, does not directly address the client's fear and resistance to self-injections, missing the opportunity to explore the underlying issues.
A client receiving chlorpromazine HCL (Thorazine) is in psychiatric home care. During a home visit, the nurse observes the client smacking her lips alternately with grinding her teeth. The nurse recognizes this assessment finding as what?
- A. Dystonia
- B. Akathisia
- C. Bradykinesia
- D. Tardive dyskinesia
Correct Answer: D
Rationale: The correct answer is D: Tardive dyskinesia. Tardive dyskinesia is a potential side effect of long-term antipsychotic use, characterized by involuntary movements like lip smacking and repetitive, purposeless movements. Choice A, dystonia, presents with sustained or repetitive muscle contractions. Choice B, akathisia, involves motor restlessness and a compelling need to be in constant motion. Choice C, bradykinesia, refers to slowness of movement typically seen in Parkinson's disease, not lip smacking and teeth grinding, which are indicative of tardive dyskinesia.
A community health nurse is caring for a group of families. The nurse should identify which of the following families is experiencing a maturational loss?
- A. A family whose only child recently died due to cancer.
- B. A family whose head of household lost her job.
- C. A family whose house was destroyed in a fire.
- D. A family whose oldest child is moving away for college.
Correct Answer: D
Rationale: The correct answer is D because maturational loss is related to developmental changes, such as children leaving for college. This type of loss is tied to the normal life transitions of individuals and can lead to feelings of grief and adjustment. Choices A, B, and C represent different types of losses. Choice A involves a traumatic loss of a child due to illness, choice B involves a financial loss impacting the head of household's job, and choice C involves a material loss due to a fire incident. While these losses are significant, they do not specifically relate to maturational loss, which is associated with expected life stage transitions.
What intervention is most important for the LPN/LVN to implement for a male client experiencing urinary retention?
- A. Apply a condom catheter.
- B. Apply a skin protectant.
- C. Encourage increased fluid intake.
- D. Assess for bladder distention.
Correct Answer: D
Rationale: The most important intervention for the LPN/LVN to implement for a male client experiencing urinary retention is to assess for bladder distention. This assessment is crucial as it helps identify the underlying cause of urinary retention, such as bladder distention or obstruction. By assessing the bladder, the LPN/LVN can determine the appropriate interventions needed, such as catheterization, medication administration, or further evaluation by the healthcare provider. Applying a condom catheter (Choice A) is more suitable for urinary incontinence, not retention. Applying a skin protectant (Choice B) is typically done to prevent skin breakdown in incontinent clients. Encouraging increased fluid intake (Choice C) may be beneficial for some urinary issues but is not the priority intervention for urinary retention.
A nurse is preparing change of shift report after the night shift using one SBAR communication tool. Which of the following data should the nurse include when reporting background information?
- A. "Blood pressure 160/92 mm Hg"
- B. "Start the first dose of penicillin at 1200"
- C. "Pain rating of 5 on a scale from 0 to 10"
- D. "Code status: do-not-resuscitate"
Correct Answer: B
Rationale: The correct answer is B. When providing background information in a shift report using the SBAR communication tool, the nurse should include details related to medication administration and orders. This helps ensure continuity of care and accurate handover of responsibilities. Choices A, C, and D do not typically fall under background information for shift reports. A blood pressure reading, pain rating, and code status are more relevant to the patient's current condition and status, rather than background information about medications or orders.