The nurse makes selections from the hospital menu for a client who is confused and suspicious of others. Which menu choice is best?
You answered this question Correctly
1. Ham and vegetable casserole
2. Cheese and
...
The nurse makes selections from the hospital menu for a client who is confused and suspicious of others. Which menu choice is best?
You answered this question Correctly
1. Ham and vegetable casserole
2. Cheese and crackers
3. Caffeine free tea
4. Correct: A client who is suspicious of others needs foods that are packaged and can
see them opened.
1. Incorrect: A client who is suspicious of others needs to be able to identify the ingredients in the food that is being eaten. A casserole contains many ingredients and the client may fear that something has been added to the food.
2. Incorrect: Finger foods are best for clients that are manic.
3. Incorrect: Drinks and foods with no caffeine are okay for the confused and suspicious client but this menu choice is not the best choice from the list here.
Question:
Two days after a myocardial infarction, a client begins reporting orthopnea and dyspnea. Further assessment reveals bi-basilar crackles, jugular venous distension, an S3 heart sound, a BP of 100/60 mm Hg, and apical pulse of 90 beats per minute. The urine output has steadily declined over the past 12 hours. What should the nurse
do first?
You answered this question Correctly
1. Notify the primary healthcare provider.
2. Increase the IV rate.
4. Observe for cardiac arrhythmias.
3. Correct: Elevate the head of the bed first. The client is reporting inability
to breathe. (Orthopnea means the client needs to sit up to breathe better.) With ANY
client having difficulty breathing, the first intervention for the nurse is to sit the client up. This client is showing s/s of heart failure.
1. Incorrect: Your next step is to call the primary healthcare provider after you do something to try to fix the problem.
2. Incorrect: Increasing the IV rate is contraindicated and would make the problem worse.
4. Incorrect: After an MI, all clients are observed for cardiac arrhythmias. This, however, does not fix the problem.
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