EAQ questions to know
A client who has had an uncomplicated myocardial infarction asks the nurse about the resumption of sexual activity. Which parameters should the nurse consider to determine the safe resumption of sexual activity? Select all that apply. The client and partner are not fearful of sexual intimacy At least between 4 and 6 weeks after the myocardial infarction When the client feels emotionally ready to resume sexual activity The point at which two flights of stairs can be climbed without dyspnea Laboratory data showing that enzyme results have returned to preinfarction levels
At least between 4 and 6 weeks after the myocardial infarction The point at which two flights of stairs can be climbed without dyspnea Most health care providers suggest waiting 4 to 6 weeks, which allows the heart to heal after a myocardial infarction. The point at which two flights of stairs can be climbed approximates the energy expended during sexual activity. Emotionally, the client or partner may never be ready; studies have shown that 45% to 50% of individuals fear resumption of sexual activity. The client may be emotionally ready to resume sexual activity before being physically ready. Enzyme studies, such as Creatine kinase (CK), Creatine kinase Myoglobin (CK-MB), Lactate dehydrogenase (LDH), and Aspartate transaminase (AST), return to expected levels after 3 to 14 days, which is too soon to resume sexual activity, according to most health care providers.
A nurse on the community's terrorism response team is reviewing triage protocols. In contrast to triage policies in local emergency situations, triage in mass casualty events does not give care to clients who have: Multiple fractures. Closed head injuries. Internal abdominal trauma. Radiation/chemical exposures.
closed head injuries Individuals with serious head injuries are not cared for immediately in mass casualty events because the need is to care for the largest number of people who have the least severe injuries. People with fractures are cared for in mass casualty events. People needing uncomplicated abdominal surgeries are cared for in mass casualty events. People with survivable radiation or chemical exposures are cared for in mass casualty events.
A client has a brain attack (stroke) that involves the right cerebral cortex and cranial nerves. What areas of paralysis should the nurse expect the client to exhibit? Select all that apply. Left leg Left arm Right leg Right arm Left side of face
left leg left arm Because nerves decussate, paralysis occurs on the side of the body opposite to the area of cerebral involvement. The right leg and right arm will not be affected because the insult is to the right cerebral cortex, and nerve fibers decussate before reaching the periphery The face is innervated by the seventh cranial nerve, which comes in pairs (right and left) that do not decussate; therefore, because injury is to the right cranial nerve, the left side of the face is unaffected.
A nurse is caring for a client with a diagnosis of varicose veins. Which clinical findings can the nurse expect to identify when assessing this client? Select all that apply. Discolored toenails Reports of leg fatigue Localized heat in a calf Reddened areas on a leg Tortuous veins in the legs Pain in lower extremities when standing
reports of leg fatigue Tortuous veins in the legs Pain in lower extremities when standing Leg fatigue is a common clinical manifestation caused by venous stasis and inadequate tissue oxygenation. Vein walls weaken and dilate resulting in distended, protruding veins that appear tortuous and darkened. As vein walls weaken and dilate venous pressure increases and the valves become incompetent; venous stasis and inadequate oxygenation result in leg pain. Discolored toenails result from a fungus under the nail or chronic hypoxia, not varicose veins. Localized heat in a calf is a sign of thrombophlebitis. Reddened areas on a leg are indicative of thrombophlebitis.
A nurse explains to a client with trigeminal neuralgia that a treatment that is effective on a temporary (6 to 18 months) basis is: Weekly intravenous injections of cobra venom A lidocaine injection of the ventral root of the eleventh spinal nerve Microvascular decompression of the blood vessels at the nerve root An alcohol injection of the peripheral branch of the fifth cranial nerve
An alcohol injection of the peripheral branch of the fifth cranial nerve A nerve block of the trigeminal (fifth cranial) nerve with alcohol is a conservative approach that lasts 6 to 18 months. Weekly intravenous injections of cobra venom have been tried but provide little, if any, relief. Lidocaine is not used; cranial nerve XI is the spinal accessory nerve that innervates the sternocleidomastoid and trapezius muscles. Microvascular decompression of the blood vessels at the nerve root is not a conservative approach; this is the most commonly used surgical procedure for trigeminal neuralgia. Neuralgia may recur in 30% of clients within six years.
Considerations when caring for a client with a total hip replacement should include which of the following? Select all that apply. Maintain the affected hip in the adduction position when moving client out of bed. Pain control should include regularly scheduled analgesics and may necessitate use of as needed medications as well. The client should sit in a chair at the correct height to encourage flexion of the joint. Frequent neurovascular assessment should be done distal to the surgical site and compared with the unaffected side. When turning, client should be log rolled to prevent leg from falling forward or backward
Pain control should include regularly scheduled analgesics and may necessitate use of as needed medications as well. Frequent neurovascular assessment should be done distal to the surgical site and compared with the unaffected side. When turning, client should be log rolled to prevent leg from falling forward or backward. Pain control should include regularly scheduled analgesics as decreased pain will aid in earlier mobilization. Assessing pain level is standard postoperative care, and pain must be managed accordingly. Frequent neurovascular assessment should be done when assessing vital signs to observe for circulatory compromise. When turning the total hip replacement client, the client should have an abductor pillow in place to assure that the hip does not become adducted. Turning as a whole prevents the leg from moving out of alignment. The affected hip should not be in the adducted position, but rather the abducted position. The client should sit in a chair high enough to minimize flexion of the joint, particularly hyperflexion, which is bending forward more than 90 degrees.
A client has a history of progressive carotid and cerebral atherosclerosis and experiences transient ischemic attacks (TIAs). The nurse explains to the client that TIAs are: Temporary episodes of neurological dysfunction Intermittent attacks caused by multiple small clots Ischemic attacks that result in progressive neurological deterioration Exacerbations of neurological dysfunction alternating with remissions
Temporary episodes of neurological dysfunction Narrowing of arteries supplying the brain causes temporary neurological deficits that last for a short period. Between attacks, neurological functioning is normal. Emboli result in a brain attack (CVA); with a CVA the damage usually is permanent, not intermittent. Ischemic attacks that result in progressive neurological deterioration occur with multiple small brain attacks; TIAs do not result in permanent damage. Exacerbations of neurological dysfunction alternating with remission are not the description of a TIA; remissions and exacerbations occur with progressive degenerative neurological disorders.
A health care provider prescribes two units of blood for a client who is bleeding. Which nursing interventions are necessary before the blood transfusion is administered? Select all that apply. Obtaining the client's vital signs Monitoring hemoglobin and hematocrit levels Allowing the blood to reach room temperature Determining typing and crossmatching of blood Using a Y-type infusion set to initiate 0.9% normal saline
obtaining vitals Determining typing and crossmatching of blood Using a Y-type infusion set to initiate 0.9% normal saline Obtaining the client's vital signs provides a baseline and should be done before the transfusion is initiated. Using a Y-type infusion set with 0.9% saline on one side of the Y is necessary to prevent an acute immunologic reaction if the donated blood is not compatible with the client's blood. A Y-type infusion set is specific for blood administration. It has a special blood filter, the drop factor is different, and it allows for quick shutoff and the administration of normal saline in the event of a transfusion reaction. The laboratory results for hemoglobin and hematocrit levels were part of the data used to determine the need for blood initially and do not need to be performed again until after the transfusion is completed. Blood must be kept cold until ready for use; if blood is kept at room temperature for 30 minutes before administration, it should be returned to the blood bank; after it is started, blood must be administered within four hours.
