Hurst Qbank Review Practice Test.
A client has been admitted for evaluation of severe anxiety and new onset panic attacks following the loss of a
... [Show More] spouse. Which client factor would the nurse consider most important in developing a plan of care?
1. Available support system
2. Perception of the situation
3. Desire to return to work
4. Coping mechanisms - CORRECT ANSWER 4. Correct. The plan of care for a client in crisis involves a complex combination of factors to achieve a positive outcome. However, the most important consideration is the client's own coping skills. Treatment and subsequent recovery is more successful when the client has the coping skills and is able to participate in the recovery process.
1. Incorrect. Although a good support system is crucial during any psychiatric or emotional crisis, this is not the most important aspect of a client's plan of care. The priority is the client. Available support systems is not the priority when developing a plan of care.
2. Incorrect. The client's own perception of the problem can enhance or detract from a successful outcome; however, there is another facet that is more critical to a client's positive outcome. The client's coping mechanisms can affect their perception of the situation.
3. Incorrect. Having a goal, such as returning to employment, is important to the client's recovery, but by itself is not enough to ensure a positive outcome for a client. Returning to work is not the priority with new onset panic attacks.
What signs/symptoms would the nurse expect to assess in a client diagnosed with multiple sclerosis (MS)?
1. Fatigue
2. Ptosis
3. Blurry vision
4. Leg weakness
5. Limited facial expression
6. Electric shock sensation when bending neck forward - CORRECT ANSWER 1., 3., 4., & 6. Correct: Multiple sclerosis causes fatigue which often comes on in the afternoon and causes weak muscles, slowed thinking, or sleepiness. Vision problems are common with this diagnosis and include blurry vision, double vision, and pain on eye movement. Partial or complete vision loss can occur in one eye. Because this disease affects nerves, symptoms often affect movement such as extremity weakness, numbness, tingling, and coordination. Electric-shock sensations that occur with certain neck movements, especially bending the neck forward (Lhermitte sign) develop because of the nerve damage that is occurring.
2. Incorrect: Drooping of one or both eyelids (ptosis) would be seen in myasthenia gravis rather than multiple sclerosis.
5. Incorrect: Limited facial expressions occur in myasthenia gravis rather than multiple sclerosis. The muscles (not nerves) that control facial expressions have been affected.
The charge nurse is reviewing multiple events reported by staff during morning shift. The nurse is aware which event requires a written incident report?
1. A client yells loudly throughout the night shift.
2. A nurse discusses client's prognosis with family.
3. An unlicensed assistive personnel (UAP) spills water pitcher onto client.
4. A nurse tears sterile gloves and applies new gloves. - CORRECT ANSWER 2. CORRECT: The purpose of an incident report is to document any incident or unusual event inconsistent with routine operations of hospital or staff routine and resulting in injury, or potential liability, for clients, family, or staff. The nurse has violated HIPAA regulations by discussing a client's medical prognosis with family members. The primary healthcare provider is responsible to discuss prognosis with client and only those individuals designated by the client.
1. INCORRECT: Although this client may disturb other clients at night, this event does not meet the criteria for an incident report.
3. INCORRECT: This event requires the UAP to intervene, providing clean clothes for the client. However, while an unfortunate occurrence, this incident would not require an incident report.
4. INCORRECT: Damaged sterile gloves must be removed and replaced immediately to prevent contamination of the field. The nurse followed the correct procedure and no report is needed.
The nurse is caring for a client who is to receive an antibiotic in 50 mL of D5W over 30 minutes using an infusion pump. The nurse will set the infusion pump to deliver how many mL per hour? Round answer to the nearest whole number. [Show Less]