RN101
Home of the Registered Nurses (RN) and
Licensed Practical Nurses (LPN)

SITUATION I

 

Question 1:

1. Maintain sitting position 30 minutes after a meal

 

Question 2:

1. places his hand under the patient's axilla to help her move up in bed

 

SITUATION II

 

Question 1:

Alteplase is a thrombolytic which will increase bleeding when used in hemorrhagic stroke

 

SITUATION III

 

Question 1:

3 - To provide independence and mobile as possible

 

SITUATION IV

 

Question 1:

1. Vital signs

2. Dilantin

 

SITUATION V

 

Question 1:

1. Monitor for skin rash. (10-14 days) notify MD

2. Perform good oral hygiene, including daily brushing and flossing. (Risk for gingival hyperplasia-dental check up)

3. Receive necessary periodic blood work. (CBC, hepatic function, and drug levels)

4. Report to the physician any problems with walking or coordination and slurred speech or nausea

 

SITUATION VI

 

Question 1:

1. Ask for assistance to log roll the patient

2. Make sure that the cervical collar is securely positioned before mobilization

 

Question 2:

Autonomic dysreflexia

 

SITUATION VII

 

Question 1:

C

 

Question 2:

Leaving the patient alone in a secluded area could precipitate agitation.

 

SITUATION VIII

 

Question 1:

1. Urinary tract infection 

2. Delirium

SITUATION IX

 

Question 1:

Explaining why blood is being taken responds to the client's concerns or fears about what is happening to her. Threatening more pain or promising to explain later ignores or postpones meeting the client's need for information. The client's statements do not reflect loss of self control requiring medication intervention.

"The tests of your blood will help us figure out what is happening to you."

 

Question 2:

The nurse should orient the client by telling him the time, date, place, and who the client with. Taking the client to his room and telling him why the door is locked does not address his disorientation. Telling the client to eat before going to the doctor reinforces his disorientation.

 

SITUATION X

 

Question 1:

Using a bed alarm enables the staff to respond immediately if the client tries to get out of bed. Sleeping in a chair at the nurse's station interferes with the client's restful sleep and privacy. Using all four bedrails is considered a restraint and unsafe practice. It is not appropriate to expect a family member to stay all night with the client.

 

SITUATION XI

 

1. Establish a set routine for rising, hygiene, meals, short rest periods, and bedtime. 
2. Engage the client in simple, brief exercises or a short walk when she gets drowsy during the day. 
3. Promote relaxation before bedtime with a warm bath or relaxing music. 

A set routine and brief exercises help decrease daytime sleeping. Decreasing caffeine and fluids and promoting relaxation at bedtime promote nighttime sleeping

 

SITUATION XII

 

Question 1:

Vulgar language is common in clients with dementia when they are having trouble communicating about a topic. Ignoring the vulgarity and distracting her is appropriate. Telling the client she is rude or to stop swearing will have no lasting effect and may cause agitation. Just leaving the room is abandonment that the client will not understand

 

SITUATION XIII

Question 1:

Make sure that the patient has her purse at all times

 

Question 2:

Any response that helps the patient reminisce with her mother (i.e. Do you miss your mother? What does she looks like? Would you like to talk about your mother?)

 

SITUATION XIV

 

Question 1:

Let the patient have a sip of water before giving the capsule. (In most practice capsule should not be open, the water moisten the patient mucosa which will aid in swallowing)

 

SITUATION XV

 

Question 1:

On the patient's right side

 

SITUATION XVI

 

Question 1:

The MMSE is useful in determining the degree of mental impairment

 

SITUATION XVII

 

Question 1:

Having the patient's spouse administer the medication