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While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?
- A. Tell the patient to just focus on the leg and cast right now.
- B. Document the sleep patterns and information in the patient’s chart.
- C. Explain that a more thorough assessment will be needed next shift.
- D. Ask the patient about usual sleep patterns and the onset of having difficulty resting.
Correct Answer: D
Rationale: The correct answer is D because asking the patient about their usual sleep patterns and onset of difficulty resting is crucial to understand the situation fully. This helps to identify any potential underlying issues contributing to the sleep disturbance. Choice A is incorrect as it dismisses the patient's concerns. Choice B is not as effective as directly addressing the patient's sleep issues. Choice C delays the assessment, potentially missing important information. By choosing answer D, the nurse can gather valuable information to address the patient's sleep problem effectively.
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Which of the following is the medication of choice for anaphylaxis that the nurse should anticipate would be ordered?
- A. Epinephrine
- B. Digoxin (Lanoxin)
- C. Theophylline (Theo-Dur)
- D. Furosemide (Lasix)
Correct Answer: A
Rationale: The correct answer is A: Epinephrine. In anaphylaxis, epinephrine is the medication of choice due to its rapid onset of action and ability to reverse severe allergic reactions. It acts by constricting blood vessels, increasing heart rate, and opening airways. This helps counteract the dangerous drop in blood pressure and airway constriction seen in anaphylaxis. Digoxin, theophylline, and furosemide are not appropriate for anaphylaxis as they do not address the immediate life-threatening symptoms of anaphylaxis.
A client with acquired immunodeficiency syndrome (AIDS) is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?
- A. Continue with the bath and tell the client not to worry
- B. Ask the physician to obtain a psychiatric consultation
- C. Listen and show interest as the client expresses feelings
- D. State that these friends’s behavior shows that they aren’t true friends
Correct Answer: C
Rationale: The correct answer is C: Listen and show interest as the client expresses feelings. It is essential for the nurse to actively listen and show empathy towards the client's emotional distress. This approach demonstrates compassion, understanding, and support for the client during a vulnerable moment, which is crucial for the therapeutic relationship. By actively listening, the nurse can validate the client's emotions and provide a safe space for them to express their feelings. This can help the client feel heard and supported, leading to improved emotional well-being.
Choices A, B, and D are incorrect:
A: Continuing with the bath and telling the client not to worry dismisses the client's emotions and fails to address their underlying feelings of loneliness and isolation.
B: Asking for a psychiatric consultation may not be necessary at this point, as the client's emotional distress can be effectively managed through therapeutic communication.
D: Stating that the friends' behavior shows they aren't true friends is judgmental and unhelpful, as it does not address
A client with hyperglycemia, which assessment finding best supports a nursing diagnosis of Deficient fluid volume?
- A. Cool, clammy skin
- B. Increased urine osmolarity
- C. Distended neck veins
- D. serum sodium level
Correct Answer: B
Rationale: The correct answer is B: Increased urine osmolarity. In hyperglycemia, the body tries to eliminate excess glucose through increased urine output, causing a concentrated urine with high osmolarity. This indicates fluid deficit. Cool, clammy skin (A) may suggest poor perfusion but not fluid volume deficit. Distended neck veins (C) are more indicative of fluid overload. Serum sodium level (D) may be elevated in fluid deficit but does not directly assess volume status like urine osmolarity does.
A patient who is suspected of having hypothyroidism should be expected which of these symptoms?
- A. tachycardia
- B. hyperthermia
- C. weight loss
- D. extreme fatigue
Correct Answer: D
Rationale: The correct answer is D, extreme fatigue, for a patient suspected of having hypothyroidism. Hypothyroidism is associated with decreased production of thyroid hormones, leading to a slower metabolism and reduced energy levels. This results in symptoms such as fatigue, weakness, and lethargy. Tachycardia (A) is more commonly associated with hyperthyroidism, where the thyroid is overactive. Hyperthermia (B) is increased body temperature, not typically a symptom of hypothyroidism. Weight loss (C) is also more commonly seen in hyperthyroidism due to increased metabolism. In summary, extreme fatigue is a hallmark symptom of hypothyroidism due to decreased thyroid hormone levels, distinguishing it from the other choices.
A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?
- A. Reassess the patient and situation.
- B. Revise the turning schedule to increase the frequency.
- C. Delegate turning to the nursing assistive personnel.
- D. Apply medication to the area of skin that is broken down.
Correct Answer: A
Rationale: The correct answer is A: Reassess the patient and situation. The nurse should reassess to determine the cause of the pressure ulcer, evaluate the effectiveness of the current turning schedule, and identify any contributing factors. This allows for a more targeted intervention plan.
B: Incorrect. Simply increasing the frequency of turning may not address the underlying issue causing the pressure ulcer.
C: Incorrect. Delegating turning to nursing assistive personnel without reassessment may not address the root cause of the pressure ulcer.
D: Incorrect. Applying medication without reassessment may not address the underlying cause of the pressure ulcer and could potentially worsen the condition.