A competent elderly client has a living will. The living will expressed the desire to
avoid resuscitation and heroic life support measures. The family members are not
supportive of this directive. Which of the following actions by the nursing staff is most
appropriate?
1. Contact the Social Services department.
2. Notify the hospital attorney.
3. Place the document on the chart.
4. Explain to the client that the conflict could invalidate the document.
Give this one a try later!
Answer: 3
Rationale: The client is competent. The wishes of the client must take priority.
The
document should first be placed on the chart and the physician notified. If
there are
concerns about the authenticity of the document, the Social Services
, department or the
unit supervisor will need to be contacted. A lack of support by the family does
not
invalidate the document.
A client has presented with a burn injury. The injury site is pale and waxy with large
flat blisters. The client asks questions about the severity of the injury and how long it will
take for this injury to heal. Based upon your knowledge, what information should be
provided to the client?
a. The wound is a partial-thickness burn, and could take up to two weeks to heal.
b. The wound is a superficial burn, and will take up to three weeks to heal.
c. The wound is a deep partial-thickness burn, and will take more than three weeks to
heal.
d. Wound healing is individualized.
Give this one a try later!
Answer: c
Rationale: The wound describes is a deep partial-thickness burn. Deep partial
thickness
wounds will take more than three weeks to heal. A superficial burn is bright
red and
moist, and might appear glistening with blister formation. The healing time for
this type
of wound is within 21 days.
The nurse is caring for a client in the ICU who sustained a traumatic injury several
days ago. During the assessment, the nurse notes that the client is hypotensive, oliguric,
and has cool pale skin and acidosis. The nurse understands that these manifestations are
,indicative of:
1. Hypovolemic shock.
2. Cardiogenic shock.
3. Septic shock.
4. Anaphylactic shock.
Give this one a try later!
Answer: 1
Rationale: Hypovolemic shock is caused by a decrease in intravascular volume.
In
hypovolemic shock, the venous blood returning to the heart decreases, and
ventricular fills drops. As a result, stroke volume, cardiac output, and blood
pressure decrease.
Hypovolemic shock affects all body systems. Clients at risk for developing
infections
leading to septic shock include those who are hospitalized, have debilitating
chronic
illnesses, or have poor nutritional status. Septic shock does not usually present
with a
client who presents with a traumatic injury. Anaphylactic shock is the result of a
widespread hypersensitivity reaction from medications, blood administration,
latex,
foods, snake venom, and insect stings.
The charge nurse is preparing assignments for the shift. Two of the clients have been
diagnosed with herpes zoster. When planning cares assignments, which of the following
nurses should be assigned to care for these clients?
1. The nurse who is pregnant at 24 weeks' gestation
2. The nurse who had chickenpox just one year ago
3. The nurse who has never had chickenpox
4. The nurse who is in her first trimester of pregnancy
, Give this one a try later!
Answer: 2
Rationale: The client who has had chickenpox is the safest choice to provide
care. The
lesions should be avoided by all pregnant women regardless of gestation. The
client who
has never had chickenpox could be infected by the disorder.
A client is admitted to the hospital with a history of squamous-cell lung cancer. Upon
admission, the client exhibits signs of arm and periorbital edema. Within the hour, the
client exhibits dyspnea, cyanosis, tachypnea, and an altered level of consciousness.
Which action should the nurse take FIRST?
1. Call the physician.
2. Administer oxygen.
3. Monitor vital signs.
4. Initiate seizure precautions.
Give this one a try later!
Answer: 2
Rationale: The superior vena cava can be compressed by mediastinal tumors
or adjacent
thoracic tumors. The most common cause is small-cell or squamous-cell lung
cancers.
Signs and symptoms can develop slowly, and include facial, periorbital, and
arm edema
as early signs. As the problem progresses, respiratory distress, dyspnea,
cyanosis,
tachypnea, and altered consciousness and neurologic deficits can occur.
Emergency
measures include the following: Provide respiratory support with oxygen, and
avoid resuscitation and heroic life support measures. The family members are not
supportive of this directive. Which of the following actions by the nursing staff is most
appropriate?
1. Contact the Social Services department.
2. Notify the hospital attorney.
3. Place the document on the chart.
4. Explain to the client that the conflict could invalidate the document.
Give this one a try later!
Answer: 3
Rationale: The client is competent. The wishes of the client must take priority.
The
document should first be placed on the chart and the physician notified. If
there are
concerns about the authenticity of the document, the Social Services
, department or the
unit supervisor will need to be contacted. A lack of support by the family does
not
invalidate the document.
A client has presented with a burn injury. The injury site is pale and waxy with large
flat blisters. The client asks questions about the severity of the injury and how long it will
take for this injury to heal. Based upon your knowledge, what information should be
provided to the client?
a. The wound is a partial-thickness burn, and could take up to two weeks to heal.
b. The wound is a superficial burn, and will take up to three weeks to heal.
c. The wound is a deep partial-thickness burn, and will take more than three weeks to
heal.
d. Wound healing is individualized.
Give this one a try later!
Answer: c
Rationale: The wound describes is a deep partial-thickness burn. Deep partial
thickness
wounds will take more than three weeks to heal. A superficial burn is bright
red and
moist, and might appear glistening with blister formation. The healing time for
this type
of wound is within 21 days.
The nurse is caring for a client in the ICU who sustained a traumatic injury several
days ago. During the assessment, the nurse notes that the client is hypotensive, oliguric,
and has cool pale skin and acidosis. The nurse understands that these manifestations are
,indicative of:
1. Hypovolemic shock.
2. Cardiogenic shock.
3. Septic shock.
4. Anaphylactic shock.
Give this one a try later!
Answer: 1
Rationale: Hypovolemic shock is caused by a decrease in intravascular volume.
In
hypovolemic shock, the venous blood returning to the heart decreases, and
ventricular fills drops. As a result, stroke volume, cardiac output, and blood
pressure decrease.
Hypovolemic shock affects all body systems. Clients at risk for developing
infections
leading to septic shock include those who are hospitalized, have debilitating
chronic
illnesses, or have poor nutritional status. Septic shock does not usually present
with a
client who presents with a traumatic injury. Anaphylactic shock is the result of a
widespread hypersensitivity reaction from medications, blood administration,
latex,
foods, snake venom, and insect stings.
The charge nurse is preparing assignments for the shift. Two of the clients have been
diagnosed with herpes zoster. When planning cares assignments, which of the following
nurses should be assigned to care for these clients?
1. The nurse who is pregnant at 24 weeks' gestation
2. The nurse who had chickenpox just one year ago
3. The nurse who has never had chickenpox
4. The nurse who is in her first trimester of pregnancy
, Give this one a try later!
Answer: 2
Rationale: The client who has had chickenpox is the safest choice to provide
care. The
lesions should be avoided by all pregnant women regardless of gestation. The
client who
has never had chickenpox could be infected by the disorder.
A client is admitted to the hospital with a history of squamous-cell lung cancer. Upon
admission, the client exhibits signs of arm and periorbital edema. Within the hour, the
client exhibits dyspnea, cyanosis, tachypnea, and an altered level of consciousness.
Which action should the nurse take FIRST?
1. Call the physician.
2. Administer oxygen.
3. Monitor vital signs.
4. Initiate seizure precautions.
Give this one a try later!
Answer: 2
Rationale: The superior vena cava can be compressed by mediastinal tumors
or adjacent
thoracic tumors. The most common cause is small-cell or squamous-cell lung
cancers.
Signs and symptoms can develop slowly, and include facial, periorbital, and
arm edema
as early signs. As the problem progresses, respiratory distress, dyspnea,
cyanosis,
tachypnea, and altered consciousness and neurologic deficits can occur.
Emergency
measures include the following: Provide respiratory support with oxygen, and
