A nurse is caring for a client.

Exhibits

A nurse is reviewing the client's medical record. After reviewing the medical record, which of the following actions should the nurse plan to take?

For each potential provider's prescription, click to specify if the potential prescription is anticipated, nonessential, or contraindicated for the client.

Encourage the client to cough.

Initiate seizure precautions.

Elevate the head of the bed.

Keep the client's head in a midline position.

Decrease oxygen to 1.5 L/min via nasal cannula.

Assist the client to the bathroom.

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"C"},"F":{"answers":"C"}}

Rationale

Interpretation of Actions:

Encourage the client to cough:
- Nonessential
  Encouraging the client to cough is not a priority in this situation. The client's neurological status is deteriorating, and the focus should be on managing intracranial pressure and ensuring airway patency rather than promoting coughing.
Initiate seizure precautions:
- Anticipated
  Seizure precautions are appropriate due to the client's declining neurological status, as seizures can occur with increased intracranial pressure or other neurological changes.
Elevate the head of the bed:
- Anticipated
  Elevating the head of the bed to 30 degrees promotes venous drainage and helps reduce intracranial pressure, which is critical given the client's symptoms.
Keep the client's head in a midline position:
- Anticipated
  Maintaining a midline head position prevents obstruction of venous outflow and helps reduce intracranial pressure.
Decrease oxygen to 1.5 L/min via nasal cannula:
- Contraindicated
  Reducing oxygen is inappropriate in this situation. The client's altered mental status and vomiting suggest potential hypoxia or increased intracranial pressure, requiring close monitoring of oxygenation rather than decreasing it.
Assist the client to the bathroom:
- Contraindicated
  Assisting the client to the bathroom is unsafe due to their altered mental status, restlessness, and risk of falls or further neurological compromise. Instead, measures to prevent overexertion, such as using a bedpan, should be implemented.

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Correct Answer is C

Explanation

A. Avoiding intercourse is not necessary unless there is discomfort, but the focus should be on managing symptoms like vaginal dryness. It is important to address the root cause of the discomfort, which is often related to hormonal changes rather than avoiding sexual activity.

B. Thickening of the vaginal tissue is not typical in older women. In fact, due to decreasing estrogen levels, vaginal tissue often becomes thinner, drier, and less elastic, which can contribute to discomfort and dryness.

C. Decreasing estrogen levels are a common cause of vaginal dryness and itching in older adult women, especially during and after menopause. Estrogen helps maintain the health of vaginal tissues, and a decrease in this hormone leads to symptoms such as dryness, itching, and discomfort.

D. Discomforts decreasing with time is not accurate. While some symptoms may improve with treatment, vaginal dryness and itching are typically chronic issues that require management, such as with estrogen therapy or lubricants, rather than resolving on their own.

A. "I can put the tablet against my cheek and gum." B. "I should chew the tablet before I swallow it." C. "I can take another dose after 2 minutes." D. "I should take this medication as soon as the pain begins."

Correct Answer is D

Explanation

A. The client should place the sublingual nitroglycerin tablet under the tongue, not against the cheek and gum. This allows for faster absorption through the mucous membranes.

B. The client should not chew the tablet. It should be allowed to dissolve under the tongue to ensure proper absorption and effectiveness.

C. The nurse should instruct the client to wait at least 5 minutes between doses. If the chest pain persists after the first dose, the client can take a second dose, but they should wait 5 minutes and not 2 minutes.

D. Sublingual nitroglycerin should be taken immediately when chest pain begins. It is used to relieve acute episodes of angina by dilating blood vessels and improving blood flow to the heart.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?

Correct Answer is C

Explanation

A nurse is providing discharge teaching to a client who has a new prescription for sublingual nitroglycerin. Which of the following statements made by the client indicates an understanding of the teaching?

Correct Answer is D

Explanation

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