d
A female client who recently had a colostomy expresses concerns about her sexual relationship with her husband. Which statement made by the nurse is appropriate? a) "We have a psychiatrist available for sexual dysfunction therapy." b) "Let me speak with your husband. He might be okay with it." c) "I would like to refer you to a support group so that you can speak with others with similar problems." d) "Give him time. He will get over it."
"I would like to refer you to a support group so that you can speak with others with similar problems." Having this client speak with someone who has had a similar surgery and concerns would be beneficial. Discussing the client's concerns with her husband does not address the client's needs. She is coping normally and does not need professional help. In fact, the client may feel that the nurse violated confidentiality
The son of an elderly client who has cognitive impairments approaches the nurse and says, "I'm so upset. The HCP says I have 4 days to decide on where my dad is going to live." The nurse responds to the son's concerns, gives him a list of types of living arrangements, and discusses the needs, abilities, and limitations of the client. The nurse should intervene further if the son makes which comment? a) "Boy, I have a lot to think about before I see the social worker tomorrow." b) "I think I can handle most of Dad's needs with the help of some home health care." c) "I am so afraid of making the wrong decision, but I can move him later if I need to." d) "I want the social worker to make this decision so Dad will not blame me."
"I want the social worker to make this decision so Dad will not blame me." Expecting the social worker to make the decision indicates that the son is avoiding participating in decisions about his father. The other responses convey that the son understands the importance of a careful decision, the availability of resources, and the ability to make new plans if needed.
A client on mechanical ventilation is receiving pancuronium I.V. as needed. Which assessment finding indicates that the client needs another pancuronium dose? a) Leg movement b) Finger movement c) Lip movement d) Fighting the ventilator
Fighting the Ventilator Pancuronium, a nondepolarizing blocking agent, is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting endotracheal intubation and paralyzing the client so he breathes in synchrony with the ventilator. Fighting the ventilator is a sign that the client needs another pancuronium dose. The nurse should administer a dose I.V. every 20 to 60 minutes. Movement of the legs, fingers, or lips has no effect on the ventilator and therefore isn't used to determine the need for another dose.
A physician orders diazepam, 10 mg I.V., for a client experiencing status epilepticus. Which statement about I.V. diazepam is true? a) It should be administered in a small vein to minimize irritation. b) It rarely causes adverse reactions. c) It may be mixed with other drugs in an infusion. d) It should be administered no faster than 5 mg/minute in an adult.
It should be administered no faster than 5 mg/minute in an adult. To prevent adverse reactions, which are common, I.V. diazepam should be administered no faster than 5 mg/minute in an adult and should be given over at least 3 minutes in children. Diazepam shouldn't be mixed with other drugs in an infusion because of the high risk of incompatibility. To help prevent extravasation, the nurse should avoid administering diazepam in a small vein. I.V. diazepam may cause cardiorespiratory depression; to detect this adverse reaction, the nurse should monitor the client's vital signs carefully during administration
Which of the following is the priority action the nurse should take when finding medications at a client's bedside? a) Leave the medications, as the client will take them after breakfast. b) Label the medications and place them back in the medication room. c) Leave the medications and seek the nurse who left them in the room. d) Remove the medications from the room and discard them into an appropriate disposal bin.
Remove the medications from the room and discard them into an appropriate disposal bin. This answer reflects best practice of nursing and medication administration. Leaving the medications creates a risk for another client to take them, or for them to get lost. Leaving them and seeking the nurse creates a risk for loss or another client taking them. It is incorrect and unsafe to label medications that were taken out by another nurse.
