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1. How should a healthcare professional assess a patient with chest pain?
- A. Assess the severity of pain and monitor ECG
- B. Administer nitroglycerin and provide oxygen
- C. Administer aspirin and provide pain relief
- D. Monitor for nausea and administer IV fluids
Correct answer: A
Rationale: When assessing a patient with chest pain, the initial step is to assess the severity of pain and monitor the electrocardiogram (ECG) to look for signs of cardiac issues. Administering nitroglycerin and oxygen (Choice B) is a treatment option for suspected cardiac chest pain but should not precede a thorough assessment. Administering aspirin and providing pain relief (Choice C) may be indicated later, but the priority is to assess the situation first. Monitoring for nausea and administering IV fluids (Choice D) is not the initial assessment for chest pain unless there are specific indications present.
2. A nurse is caring for a client who has heart failure and is receiving digoxin. Which of the following findings should the nurse identify as a sign of digoxin toxicity?
- A. Bradycardia
- B. Tachycardia
- C. Hypotension
- D. Increased appetite
Correct answer: A
Rationale: Corrected Rationale: Bradycardia is a common sign of digoxin toxicity. Digoxin, a medication used to treat heart failure, works by slowing down the heart rate and increasing the force of heart contractions. Excessive levels of digoxin can lead to toxicity, causing bradycardia (slow heart rate), among other symptoms. Tachycardia (fast heart rate) and hypotension (low blood pressure) are not typically associated with digoxin toxicity. Increased appetite is not a recognized sign of digoxin toxicity; instead, gastrointestinal symptoms like nausea, vomiting, and anorexia are more common.
3. A nurse is reviewing the medical record of a client with dementia. Which of the following findings should the nurse address first?
- A. Psychosocial stressors
- B. Restlessness and agitation
- C. Frequent wandering at night
- D. Urinary incontinence
Correct answer: B
Rationale: In clients with dementia, restlessness and agitation are important symptoms that the nurse should address first. These symptoms can indicate underlying issues such as pain, discomfort, or unmet needs, and addressing them promptly can prevent complications. Psychosocial stressors may contribute to the client's condition but should not be the initial priority. Frequent wandering at night and urinary incontinence are also common in dementia but do not pose immediate risks compared to restlessness and agitation.
4. Which of the following interventions should the nurse prioritize for a client with dementia who is at risk of falls?
- A. Use restraints to prevent the client from leaving the bed
- B. Use a bed exit alarm system to notify staff when the client attempts to leave the bed
- C. Encourage frequent ambulation with assistance
- D. Raise all four side rails to prevent falls
Correct answer: B
Rationale: The correct answer is B. Using a bed exit alarm system is a non-restrictive intervention that alerts staff when the client tries to leave the bed, promoting safety and preventing falls. Choice A is incorrect because using restraints can have adverse effects and should be avoided whenever possible. Choice C is not the priority for a client at risk of falls due to dementia as it may increase the risk of falls without proper supervision. Choice D is also not recommended as raising all four side rails can lead to restraint and should be used cautiously, if at all. Therefore, the best option is to use a bed exit alarm system to ensure the client's safety while allowing some freedom of movement.
5. How should a healthcare provider assess and manage a patient with hyperthyroidism?
- A. Administer beta-blockers and monitor for signs of thyroid storm
- B. Encourage a high-protein, low-iodine diet
- C. Monitor for signs of bradycardia
- D. Provide iodine supplements and check for arrhythmias
Correct answer: A
Rationale: Administering beta-blockers is the initial management for hyperthyroidism to control symptoms such as tachycardia and tremors. Monitoring for signs of thyroid storm is crucial as it is a life-threatening complication of hyperthyroidism. Encouraging a high-protein, low-iodine diet (choice B) is not the primary intervention for managing hyperthyroidism. Monitoring for signs of bradycardia (choice C) is not typically seen in hyperthyroidism, as it often presents with tachycardia. Providing iodine supplements and checking for arrhythmias (choice D) are contraindicated in hyperthyroidism as they can worsen the condition.
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