Nokea
When a male Korean-American client looks away when asked by the nurse to describe his problem, what is the best initial nursing action?
- A. Ask for assistance from social services to find a Korean interpreter.
- B. Establish indirect eye contact with the client.
- C. Allow several minutes for the client to respond.
- D. Repeat the question using simpler language.
Correct Answer: C
Rationale: In this scenario, the best initial nursing action is to allow several minutes for the client to respond. This approach respects the cultural norms of the client, as in some cultures, direct eye contact may be perceived as disrespectful or intrusive. By giving the client time to gather his thoughts and respond at his own pace, the nurse promotes effective communication and demonstrates cultural sensitivity. Asking for assistance from social services to find a Korean interpreter (Choice A) may be necessary for further communication but is not the best initial action. Establishing indirect eye contact (Choice B) may still make the client uncomfortable. Repeating the question using simpler language (Choice D) may not address the underlying cultural aspect affecting the client's response.
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A client with a history of hypertension is prescribed a beta-blocker. Which client statement indicates that further teaching is needed?
- A. 'I will take my medication in the morning before breakfast.'
- B. 'I should avoid eating foods high in potassium.'
- C. 'I should change positions slowly to avoid dizziness.'
- D. 'I should avoid abrupt discontinuation of the medication.'
Correct Answer: B
Rationale: The correct answer is B: 'I should avoid eating foods high in potassium.' This statement indicates a misunderstanding as beta-blockers do not typically affect potassium levels. The other choices (A, C, and D) are all appropriate statements for a client prescribed a beta-blocker. Choice A shows understanding of the timing of medication administration, choice C addresses orthostatic hypotension concerns, and choice D highlights the importance of not abruptly stopping the medication to prevent adverse effects.
An adult client comes to the clinic and reports his concern over a lump that 'just popped up on my neck about a week ago.' In performing an examination of the lump, the nurse palpates a large, non-tender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these findings suggest?
- A. Malignancy
- B. Infection
- C. Benign cyst
- D. Lymphadenitis
Correct Answer: A
Rationale: The findings of a large, non-tender, hardened lymph node, especially in the absence of overlying tissue inflammation, are indicative of malignancy. These characteristics raise suspicion for cancer, prompting the need for further investigation. Choice B, Infection, is incorrect because infection would typically present as a tender and possibly swollen lymph node. Choice C, Benign cyst, is incorrect as cysts are usually soft and movable. Choice D, Lymphadenitis, is incorrect as lymphadenitis usually presents with tender and enlarged lymph nodes in response to an infection.
A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which assessment finding is most concerning?
- A. INR of 3.5
- B. Prothrombin time (PT) of 15 seconds
- C. Headache
- D. Blood pressure of 140/90 mmHg
Correct Answer: C
Rationale: The correct answer is C. A headache in a client with a history of atrial fibrillation receiving warfarin (Coumadin) is concerning as it may indicate bleeding, which requires immediate assessment and intervention. Headaches can be a symptom of increased intracranial pressure due to bleeding, especially in patients on anticoagulants. Options A and B are within acceptable ranges for a client on warfarin therapy, indicating that the medication is effectively managing the clotting times. Option D, a blood pressure of 140/90 mmHg, while elevated, is not directly related to the client's condition of atrial fibrillation and warfarin therapy.
During the initial visit, which intervention is most important for the nurse to implement?
- A. Determine how the client is cared for when the caregiver is not present.
- B. Develop a client needs assessment and review it with the caregiver.
- C. Evaluate the caregiver's ability to care for the client's needs.
- D. Review with the caregiver the interventions provided each day.
Correct Answer: A
Rationale: The most important intervention for the nurse to implement during the initial visit is to determine how the client is cared for when the caregiver is not present. This is crucial for ensuring continuous and adequate care, especially for a bed-bound client with multiple sclerosis who relies heavily on the caregiver. While developing a client needs assessment (choice B) and evaluating the caregiver's ability (choice C) are important, understanding the care plan in the caregiver's absence takes precedence. Reviewing daily interventions with the caregiver (choice D) is valuable but not as critical as knowing the care plan during the caregiver's absence.
The nurse is reinforcing home care instructions with a client who is being discharged following a transurethral resection of the prostate (TURP). Which intervention is most important for the nurse to include in the client's instructions?
- A. Avoid strenuous activity for 6 weeks.
- B. Report fresh blood in the urine.
- C. Take acetaminophen for fever of 101°F.
- D. Consume 6 to 8 glasses of water daily.
Correct Answer: B
Rationale: Reporting fresh blood in the urine is crucial following a TURP procedure as it may indicate a complication such as bleeding or clot formation. This symptom requires immediate attention to prevent further complications. Choices A, C, and D are important aspects of post-TURP care, but identifying and reporting fresh blood in the urine take precedence due to its association with potential serious complications.