Prometric Flashcards

How is the neurovascular status of an extremity cast from the ankle to the thigh to be evaluated by the nurse?

Answer: Press and release the customer's toenails.

To assess neurovascular status in a casted extremity, nurses must check for capillary refill, sensation, and motor function distal to the injury. Pressing and releasing the toenails evaluates capillary refill, which indicates adequate blood flow to the extremity. This is a crucial part of the "5 Ps" assessment (Pain, Pallor, Pulselessness, Paresthesia, Paralysis) to detect potential compartment syndrome or nerve damage.

An outpatient radiation therapy appointment has been set for a client with breast cancer who underwent chemotherapy following a lumpectomy. When a patient is getting radiation, what critical nurse intervention is there?

Answer: Every day, check for redness or irritation at the radiated location.

Radiation therapy can cause significant skin reactions, including redness, dryness, itching, and irritation, often referred to as radiation dermatitis. Daily assessment of the radiated skin area by the nurse is crucial to monitor for these adverse effects. Early detection allows for timely interventions to manage symptoms, prevent complications like infection, and ensure patient comfort and adherence to treatment.

A patient diagnosed with antisocial behavior and personality disorder is admitted to the hospital. The customer is candidly talking about their interpersonal issues with their family, their employer at work, and the individual who stole the money. There are currently criminal charges against the client. Which behavior suggests that the patient is fulfilling the objectives of treatment?

Answer: Plans for all potential study outcomes are discussed.

Patients with antisocial personality disorder often struggle with impulsivity, lack of empathy, and failure to consider consequences. Discussing plans for all potential study outcomes demonstrates an increased capacity for foresight, responsibility, and problem-solving. This indicates a positive shift towards more adaptive coping mechanisms and a willingness to engage in treatment goals, which typically involve improving judgment and understanding the impact of their actions.

A patient admitted to the hospital has severe preeclampsia. How can a nurse make sure she is physically safe first?

Answer: Put her under seizure control measures.

Severe preeclampsia carries a significant risk of eclampsia, which is the onset of seizures in a woman with preeclampsia. Therefore, the nurse's priority is to implement seizure precautions to ensure the patient's physical safety should a seizure occur. This includes padding side rails, ensuring a patent airway, and having emergency equipment readily available, as seizures can lead to serious injury or death for both mother and fetus.

Which of the following statements made by a type 2 diabetic client suggests to the nurse that more nutrition education is required?

Answer: I'm allowed to consume as much diet fruit as I like.

While "diet" or "sugar-free" foods might seem healthier, many fruits, even in their natural form, contain significant amounts of natural sugars (fructose) and carbohydrates. Consuming "as much as I like" of any food, including fruit, can still lead to elevated blood glucose levels in a person with type 2 diabetes. This statement indicates a misunderstanding of carbohydrate counting and portion control, highlighting the need for further nutrition education.

It is discovered that a child has a dust allergy. A lesson plan for the parents is being created by the nurse. What needs to be on the nurse's plan?

Answer: Dust particles in the air can be reduced by damp-dusting the house.

For a child with a dust allergy, reducing exposure to dust mites and dust particles is paramount. Damp-dusting is an effective method because the moisture helps to trap and remove dust particles rather than simply scattering them into the air, as dry dusting might do. This practical intervention directly addresses the allergen source and helps create a healthier environment for the child.

A patient who has recently begun taking haloperidol (Haldol) is shown pacing and shifting their weight between their feet. In the client's chart, what adverse effects does the nurse record?

Answer: Akathisia

Akathisia is an extrapyramidal side effect (EPS) of antipsychotic medications like haloperidol, characterized by a subjective feeling of inner restlessness and an objective need to be in constant motion. The patient's pacing and shifting weight are classic manifestations of akathisia. It is distinct from Parkinsonism, acute dystonia, and tardive dyskinesia.

After spending many weeks in a mental unit, a patient frequently discusses delusional material. Which of the nurse's responses is most beneficial?

Answer: Urge the client to concentrate on matters of reality.

When a patient is experiencing delusions, it is important for the nurse to neither directly challenge the delusion nor reinforce it. The most therapeutic approach is to gently redirect the conversation to reality-based topics and activities. This helps to ground the patient, reinforce reality, and avoid engaging in the delusional system, while still maintaining a supportive and non-confrontational stance.

A tonic-clonic seizure is occurring in a client. What nursing action should be prioritized during the tonic-clonic phase of a seizure?

Answer: Keep the client safe from harm.

During the tonic-clonic phase of a seizure, the immediate priority is to protect the client from injury. This involves actions like easing the client to the floor, removing nearby objects that could cause harm, and protecting their head. While creating a clear airway and rotating the client to the side are important, they are often secondary to preventing physical trauma during the violent movements of a tonic-clonic seizure.

Adolescent with a diagnosis of anorexia nervosa is admitted to the psychiatric unit by a nurse. What is the main benefit that anorexic clients receive from their condition?

Answer: lowering anxiety through eating in moderation

Anorexia nervosa is characterized by severe restriction of food intake, which provides individuals with a sense of control over their bodies and lives. This perceived control often serves as a maladaptive coping mechanism to reduce overwhelming anxiety and feelings of powerlessness. While the term "eating in moderation" is inaccurate for anorexia, the underlying benefit is the reduction of anxiety through strict control over eating behaviors.

A myelomeningocele-afflicted infant is being nursed by a nurse. What kind of nursing care should be given to this baby right away?

Answer: Putting on nonadherent, sterile, and moist dressings for the sac

A myelomeningocele is a severe form of spina bifida where the spinal cord and nerves protrude, forming a sac. The immediate priority in nursing care for a newborn is to protect this delicate sac from injury, infection, and drying out. Applying a sterile, nonadherent, and moist dressing helps maintain the integrity of the sac, prevents infection, and keeps the exposed neural tissue viable until surgical repair can be performed.