A nurse is caring for a 24-year-old female client who was admitted to the emergency unit following a horseback riding accident.
Increase the propofol infusion
Assess the client's pain
Notify the social worker the client is awake
Have the client sign consent forms for procedures already performed
Consider extubating the client
Determine the client’s decision-making ability
Decrease the noise and light stimuli in the room as much as possible
Explain all procedures
Correct Answer : B,F,G,H
Choice B rationale: Assessing the client's pain is crucial as the client becomes more aware. Pain management is essential for comfort and recovery. As the client wakes up, they may begin to experience pain and discomfort, which should be promptly addressed.
Choice F rationale: Determining the client’s decision-making ability is important as the client wakes up to assess their cognitive status and ability to participate in their own care decisions. This helps in planning further care and interventions appropriately.
Choice G rationale: Decreasing the noise and light stimuli in the room as much as possible helps to create a calm environment, which is important for a patient recovering from trauma and surgery. It helps reduce anxiety and agitation as the client becomes more aware of their surroundings.
Choice H rationale: Explaining all procedures is essential for the client’s understanding and cooperation. Clear communication helps reduce anxiety and ensures that the client knows what to expect, which is important for their overall comfort and trust in the healthcare team.
Choice A rationale: Increasing the propofol infusion is incorrect because it is necessary to assess the client’s awareness and response to the current sedation level. Over-sedating the client can delay recovery and obscure their neurological status.
Choice C rationale: Notifying the social worker the client is awake is not immediately necessary at this stage. The focus should be on the client's medical and physical condition first.
Choice D rationale: Having the client sign consent forms for procedures already performed is inappropriate because the client may not be in a suitable mental state to provide informed consent due to recent sedation and trauma.
Choice E rationale: Considering extubating the client is premature. The decision to extubate should be based on a thorough assessment of the client’s readiness, including their ability to maintain their airway and adequate ventilation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
Mixed berries are rich in antioxidants and nutrients, but they do not specifically provide the calcium and vitamin D necessary to support bone health in postmenopausal women, who are at increased risk for osteoporosis.
Choice B rationale
Low-fat yogurt is a good source of calcium and vitamin D, which are vital for maintaining bone density and preventing osteoporosis in postmenopausal women. These nutrients are crucial as estrogen levels drop, increasing the risk of bone loss.
Choice C rationale
Carrots are high in beta-carotene and fiber but do not significantly contribute to calcium and vitamin D intake. While beneficial for overall health, they are not the primary focus for bone health in postmenopausal women.
Choice D rationale
Beets offer various vitamins and minerals but lack substantial amounts of calcium and vitamin D. They are not emphasized for bone health in postmenopausal women, who need to prioritize nutrients that support bone density.
Correct Answer is ["A","B","E"]
Explanation
Choice A rationale
Raspberries are an excellent source of dietary fiber, with approximately 8 grams of fiber per cup. They are rich in both soluble and insoluble fibers, which help promote healthy digestion and bowel regularity. The high fiber content in raspberries can help prevent and alleviate constipation, which is particularly beneficial for individuals with hemorrhoids.
Choice B rationale
Oatmeal is another high-fiber food, providing about 4 grams of fiber per cup. It contains a type of soluble fiber called beta-glucan, which forms a gel-like substance in the intestines, helping to soften stool and improve bowel movements. Including oatmeal in the diet can help reduce the discomfort associated with hemorrhoids.
Choice C rationale
Scrambled eggs are a good source of protein but are low in dietary fiber. They do not contribute to increasing the fiber intake needed to alleviate hemorrhoid symptoms. Although they can be part of a balanced diet, they are not specifically beneficial for a high-fiber diet.
Choice D rationale
Bacon slices are high in fat and low in fiber. Consuming high-fat foods can lead to constipation, which can worsen hemorrhoid symptoms. Bacon does not provide the necessary fiber to promote healthy digestion and bowel movements.
Choice E rationale
Raisin bran muffins are a high-fiber food option, with both the bran and raisins contributing to their fiber content. Bran is rich in insoluble fiber, which adds bulk to the stool and helps prevent constipation. Raisins also contain fiber, making raisin bran muffins a suitable choice for individuals with hemorrhoids.
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