Ethics, Processing, and Care
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NCLEX-PN › Ethics, Processing, and Care
A client calls the clinic and tells the nurse that her daughter has just been stung by a bee on the arm. She is worried that her daughter will have a severe reaction. What should the nurse do?
Tell the client to call back if the condition worsens
Ask the client if her daughter has ever been stung by a bee in the past
Instruct the client to keep the arm elevated until swelling goes away
Advise the client to bring her daughter to the emergency room
Explanation
The nurse does not have reason to suspect that the child will have an allergic reaction before symptoms are present. Thus, the patient should call back or come to the emergency room if symptoms present.
The nurse is caring for a patient with severe agoraphobia. What area of the hospital should the nurse avoid with the patient?
Wide-open spaces
Areas with lots of needles
Areas with lots of people
Enclosed areas
Explanation
A patient with agoraphobia has a fear of wide-open spaces.
A 4-year-old child is admitted to the hospital after his family was in a car crash, where his parents died. The child keeps asking you to bring his parents back to life. The nurse knows that:
This is a normal reaction
The child is delusional and may have suffered a concussion as a result of the crash
The child is depressed
The child has not seen a person die before
Explanation
This is a normal reaction for a young child, who may not fully understand death. These requests are not necessarily indicative of delusion or depression.
A nurse administers one unit of packed red blood cells. 4-6 hours later, what change can be expected in the patient's hemoglobin levels?
3% increase
15% increase
5% decrease
20% increase
Explanation
A nurse should expect to see an approximately 3% increase in the recipient's hemoglobin 4-6 hours after the administration of one unit of packed red blood cells.
The nurse is caring for a patient with severe agoraphobia. What area of the hospital should the nurse avoid with the patient?
Wide-open spaces
Areas with lots of needles
Areas with lots of people
Enclosed areas
Explanation
A patient with agoraphobia has a fear of wide-open spaces.
A patient reports to urgent care for colicky pain in the upper right quadrant that they rate as a seven out of ten. The night before they ate a fatty meal with two glasses of wine. Which of the following tests would help you asses for cholecystitis?
Murphy's sign
Mc Burney's point
Psoas sign
Rovsing's sign
Explanation
A positive Murphy's sign is an indication of cholecystitis, or gallbladder inflammation. Testing for Murphy's sign is performed during an abdominal exam by asking the patient to breathe out slowly while the fingers of the examiner are slid under the right costal margin and held in place with firm pressure. The patient is then asked to inhale, which forces the abdominal contents upward. Murphy's sign is considered positive if the patient winces or flinches when breathing in, due to pain when the inflamed gallbladder comes in contact with the examiner's fingertips.
Rovsing's sign, psoas sign, and McBurney's point are all tests for appendicitis.
A nurse administers one unit of packed red blood cells. 4-6 hours later, what change can be expected in the patient's hemoglobin levels?
3% increase
15% increase
5% decrease
20% increase
Explanation
A nurse should expect to see an approximately 3% increase in the recipient's hemoglobin 4-6 hours after the administration of one unit of packed red blood cells.
A patient reports to urgent care for colicky pain in the upper right quadrant that they rate as a seven out of ten. The night before they ate a fatty meal with two glasses of wine. Which of the following tests would help you asses for cholecystitis?
Murphy's sign
Mc Burney's point
Psoas sign
Rovsing's sign
Explanation
A positive Murphy's sign is an indication of cholecystitis, or gallbladder inflammation. Testing for Murphy's sign is performed during an abdominal exam by asking the patient to breathe out slowly while the fingers of the examiner are slid under the right costal margin and held in place with firm pressure. The patient is then asked to inhale, which forces the abdominal contents upward. Murphy's sign is considered positive if the patient winces or flinches when breathing in, due to pain when the inflamed gallbladder comes in contact with the examiner's fingertips.
Rovsing's sign, psoas sign, and McBurney's point are all tests for appendicitis.
A client calls the clinic and tells the nurse that her daughter has just been stung by a bee on the arm. She is worried that her daughter will have a severe reaction. What should the nurse do?
Tell the client to call back if the condition worsens
Ask the client if her daughter has ever been stung by a bee in the past
Instruct the client to keep the arm elevated until swelling goes away
Advise the client to bring her daughter to the emergency room
Explanation
The nurse does not have reason to suspect that the child will have an allergic reaction before symptoms are present. Thus, the patient should call back or come to the emergency room if symptoms present.
A 4-year-old child is admitted to the hospital after his family was in a car crash, where his parents died. The child keeps asking you to bring his parents back to life. The nurse knows that:
This is a normal reaction
The child is delusional and may have suffered a concussion as a result of the crash
The child is depressed
The child has not seen a person die before
Explanation
This is a normal reaction for a young child, who may not fully understand death. These requests are not necessarily indicative of delusion or depression.