Strategy: Answers are a mix of assessments and implementations.

Does this
situation require assessment? Yes.
(1) implementation, done to prevent swelling and venous congestion, not helpful to
reduce pain
due to circulatory impairment
(2) assessment, not helpful to reduce pain due to circulatory impairment, should not
palpate wet
cast, would result in depressions causing pressure
(3) implementation, pain important diagnostic symptom, should not be suppressed
or masked
(4) correctassessment, pain main symptom of circulatory impairment from cast,
pressing nail of great toe indicates circulatory function, compare speed with which
color returns with result on the opposite side, sluggish return indicates circulatory
impairment, too rapid return indicates venous congestion
88. The nurse is caring for clients in the skilled nursing facility. Which of the
following clients require the nurses IMMEDIATE attention?
1. A client admitted for a cerebral vascular accident (CVA) whose prescription for
warfarin (Coumadin) expired two days ago.
2. A client in pain who was receiving morphine in an acute care institution and was
transferred with a prescription for acetaminophen with codeine.
3. A client who has dysuria and foul-smelling, cloudy, dark amber urine.
4. An immunosuppressed client who has not received an influenza immunization.
Strategy: Determine the least stable client
(1) correctduration of Coumadin 25 days, client at risk for a repeat CVA
(2) anticoagulant takes priority, client still receiving pain medication
(3) painful urination, may indicate infection
(4) anticoagulant takes priority
89. An extremely agitated client is receiving haloperidol (Haldol) IM every
30 minutes while in the psychiatric emergency room. The MOST important
nursing intervention is to
1.
2.
3.
4.

monitor vital signs, especially blood pressure, every 30 minutes.

remain at the clients side to provide reassurance.
tell the client the name of the medication and its effects.
monitor the anticholinergic effects of the medication.

Strategy: Answers are a mix of assessments and implementations. Is this a

situation that requires assessment? Yes. Is there an appropriate
assessment? Yes.
(1) correctassessment, monitoring vital signs is of utmost importance to ensure
client safety and physiological integrity; rapid neuroleptization is a pharmacological
intervention used to rapidly diminish severe symptoms that accompany acute
psychosis; alpha-adrenergic blockade of peripheral vascular system lowers BP and
causes postural hypotension
(2) implementation, should be done, but is not highest priority
(3) implementation, should be done, but is not highest priority
(4) assessment, circulatory system takes priority