The registered nurse (RN) is developing the plan of care for a client who
is admitted for alcohol detoxification. Which goal should be most
important for the RN to primarily focus the client's care?
The client maintains optimal nutritional status.
The client will remain alert and oriented.
The...
The registered nurse (RN) is developing the plan of care for a client who
is admitted for alcohol detoxification. Which goal should be most
important for the RN to primarily focus the client's care?
The client maintains optimal nutritional status.
The client will remain alert and oriented.
The client will remain free from injury.
The client will remain alcohol free during hospitalization.
(Ans- The client will remain free from injury.
Rationale
The client is at highest risk for injury due to altered cognitive and
sensory disturbances as well as delirium tremors during withdrawal.
Remaining free from injury is the most important goal for the acute
phase of alcohol withdrawal.
A registered nurse (RN) is performing a mini-mental state examination
(MMSE) for a client who is being admitted to an assisted living
community. Which communication techniques should the RN
implement to decrease anxiety in the client? (Select all that apply.)
,Select all that apply
Use simple sentences during the examination.
Move to another question if the client seems confused.
Reduce environmental detractors during the examination.
Allow family to answer for the client to decrease frustration.
Ask questions one at a time to decrease confusion.
(Ans- Use simple sentences during the examination.
Reduce environmental detractors during the examination.
Ask questions one at a time to decrease confusion.
Rationale
Communication techniques for clients with cognitive impairments
should be simple, without environmental distractions, and direct.
The registered nurse (RN) is interviewing a female client who states she
has a persistent productive cough during the winter caused by
,bronchitis. Which additional finding should the RN assess for
bronchitis?
Phlegm production and wheezing.
Smoking history.
Hemoptysis.
Night sweats.
(Ans- Phlegm production and wheezing.
Rationale
A chronic seasonal cough related to bronchitis is likely accompanied
with phlegm production and wheezing. Although smoking can
contribute to a chronic cough, the typical seasonal cough is an
inflammatory reaction to seasonal changes.
The registered nurse (RN) is caring for a client with peptic ulcer disease
(PUD). What assessment should the RN identify and document that is
consistent with PUD? (Select all that apply).
Select all that apply
Hematemesis.
Gastric pain on an empty stomach.
, Colic-like pain with fatty food ingestion.
Intolerance of spicy foods.
Diarrhea and stearrhea.
(Ans- Hematemesis.
Gastric pain on an empty stomach.
Intolerance of spicy foods.
Rationale
Manifestations of PUD include hematemesis, gastric pain, and spicy
food intolerance.
The registered nurse (RN) is administering haloperidol 0.5 mg IM PRN to
a client for the first time. What side effects should the RN assess the
client for during the initial dose?
Bradykinesia.
Dystonia.
Somatization.
Akathisia. (Ans- Dystonia.
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