A nurse is caring for a client diagnosed with deep vein thrombosis who suddenly complains of severe chest pain, shortness of breath, and is extremely anxious. The nurse suspects that the client may have developed a pulmonary embolism. Which intervention should the nurse perform first?

Perform a 12-lead electrocardiogram and call a rapid response.

Elevate the head of the bed and apply 2 liters of nasal oxygen.

Instruct the client to remain calm and administer lorazepam.

Increase the intravenous rate from 80 mL to 100 mL/hr.

Answer and Explanation

The Correct Answer is B

Choice A reason:
Performing a 12-lead electrocardiogram and calling a rapid response team are important steps when a pulmonary embolism is suspected. However, these actions are not the immediate first-line interventions. The priority is to address the client's oxygenation needs to prevent further hypoxemia and potential cardiac arrest.

Choice B reason:
Elevating the head of the bed and applying 2 liters of nasal oxygen is the most appropriate initial intervention. This position helps improve the expansion of the lungs and oxygenation, while the supplemental oxygen can help alleviate hypoxemia, which is critical in the management of a pulmonary embolism.

Choice C reason:
While ensuring the client remains calm is beneficial, administering lorazepam is not the first-line treatment for a suspected pulmonary embolism. Lorazepam may be used for its anxiolytic effects, but it does not address the immediate life-threatening issues of oxygenation and potential hemodynamic instability.

Choice D reason:
Increasing the intravenous rate may be considered to maintain adequate hydration and venous return, but it is not the first intervention for a suspected pulmonary embolism. The priority is to stabilize the client's respiratory status and oxygenation.

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Correct Answer is B

Explanation

Choice A Reason:
Weekly aerobic exercise at a gym is generally beneficial for joint health and is not a predisposing factor for osteoarthritis. Regular physical activity helps maintain joint flexibility, muscle strength, and overall health, which can actually help prevent the development of osteoarthritis.

Choice B Reason:
Vitamin D deficiency has been associated with an increased risk of osteoarthritis. Vitamin D is essential for bone health, and a deficiency can lead to changes in bone structure and strength, potentially contributing to the development and progression of osteoarthritis.

Choice C Reason:
A weight of less than 60 kg does not typically predispose an individual to osteoarthritis. In fact, maintaining a healthy weight can reduce the risk of developing osteoarthritis, as excess body weight can increase the stress on joints.

Choice D Reason:
Trauma can lead to post-traumatic osteoarthritis, which is a form of osteoarthritis that develops after an injury to a joint. Traumatic injuries can damage the cartilage and bone, leading to degenerative changes and osteoarthritis.

A. Mandated activities. B. Visitor restrictions. C. Structured programming. D. Peer pressure.

Correct Answer is C

Explanation

Choice A reason:
Mandated activities are part of a therapeutic milieu, but they are not the primary element that contributes to the stability of a client with schizophrenia. While these activities provide a routine, they do not encompass the comprehensive support system that structured programming offers.

Choice B reason:
Visitor restrictions can be a component of a therapeutic milieu, particularly in inpatient settings, to ensure a safe and controlled environment. However, this is not typically what is missing in the home environment that leads to decompensation.

Choice C reason:
Structured programming is a key element of the therapeutic milieu that provides a stable and predictable environment, which is often lacking at home. This structure includes scheduled therapy sessions, social interactions, and activities that are designed to improve coping skills and social functioning. The consistency and predictability of structured programming can significantly benefit individuals with schizophrenia, helping them maintain functional stability.

Choice D reason:
Peer pressure is not a therapeutic aspect of the milieu. In fact, peer pressure can sometimes be negative. However, positive peer interactions and support are important in a therapeutic setting, as they can provide encouragement and a sense of community.

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A nurse is caring for a client diagnosed with deep vein thrombosis who suddenly complains of severe chest pain, shortness of breath, and is extremely anxious. The nurse suspects that the client may have developed a pulmonary embolism. Which intervention should the nurse perform first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 40-year-old client reports chronic lower back pain and stiffness. X-rays of the lumbar spine confirm the diagnosis of moderate to severe osteoarthritis. The nurse identifies which predisposing factor may have led to these degenerative changes?

Correct Answer is B

Explanation

A client diagnosed with schizophrenia functions well during hospitalization but decompensates after discharge. What does the therapeutic milieu provide that may be missing in the home environment?

Correct Answer is C

Explanation

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