Nokea
A nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. When collecting data from this client, the nurse should expect to find which of the following early indications of hypoxia?
- A. Bradypnea
- B. Peripheral edema
- C. Cyanosis
- D. Hypertension
Correct Answer: D
Rationale: Early signs of hypoxia include tachypnea, restlessness, and hypertension due to sympathetic nervous system activation.
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A nurse is caring for a school-age child who has metastatic osteosarcoma. While the parents are away, the child is crying and asks the nurse if she is going to die. Which of the following is an appropriate response by the nurse?
- A. Let's talk about what activities you are going to participate in tomorrow.
- B. This is something you should discuss with your parents when they return.
- C. Let's talk about it. Tell me more about what you are thinking.
- D. You need to focus on getting better instead of what may or may not happen.
Correct Answer: C
Rationale: Encouraging the child to express feelings allows the nurse to provide emotional support.
A nurse is caring for a client who wants information about a complementary or alternative healing modality to help her reduce stress. The nurse should suggest which of the following modalities in which the client can practice poses and meditation to achieve wellness?
- A. Reiki
- B. Aromatherapy
- C. Acupuncture
- D. Yoga
Correct Answer: D
Rationale: Yoga combines physical postures, breathing exercises, and meditation to reduce stress and promote well-being.
A nurse is preparing a client for magnetic resonance imaging (MRI). Which of the following statements should the nurse include when reinforcing teaching?
- A. You'll have to remove metal objects such as watches and body jewelry.
- B. Your exposure to radiation will be minimal.
- C. You will not be able to talk to the technician during the procedure.
- D. Unlike an x-ray, the MRI allows you to move around a bit.
Correct Answer: A
Rationale: The correct answer is A: You'll have to remove metal objects such as watches and body jewelry. This is important for MRI safety as the magnetic field can interact with metal objects, causing harm or image distortion. Removing metal ensures the client's safety during the procedure. Choice B is incorrect as MRI does not involve radiation exposure but magnetic fields. Choice C is incorrect as communication with the technician is usually possible through an intercom system. Choice D is incorrect as clients must remain still during an MRI to prevent image blurring.
A nurse is caring for a client who has dyspnea, crackles, and 3+ bilateral pitting pedal edema. Which of the following serum sodium levels should the nurse identify as an indication of fluid volume excess?
- A. 116 mEq/L
- B. 136 mEq/L
- C. 142 mEq/L
- D. 167 mEq/L
Correct Answer: A
Rationale: The correct answer is A (116 mEq/L). A low serum sodium level indicates dilutional hyponatremia, which can occur in fluid volume excess. In this case, the client's symptoms of dyspnea, crackles, and pedal edema point towards fluid overload. A serum sodium level of 116 mEq/L reflects dilution due to excess fluid in the body, indicating fluid volume excess. Choices B, C, and D have normal to high sodium levels, which do not correlate with fluid volume excess. Therefore, A is the most appropriate choice based on the client's clinical presentation.
A nurse is developing a therapeutic relationship with a client. The nurse should perform which of the following actions during the working phase of a therapeutic relationship?
- A. Determine the reason the client sought care.
- B. Instruct the client about methods to achieve goals.
- C. Discuss the client's new skill sets.
- D. Review the client's demographic information.
Correct Answer: B
Rationale: The correct answer is B: Instruct the client about methods to achieve goals. During the working phase of a therapeutic relationship, the nurse focuses on helping the client achieve their goals through guidance, education, and collaboration. Instructing the client about methods to achieve goals empowers them to actively participate in their care and progress towards wellness. This action promotes client autonomy and self-efficacy, key components of a therapeutic relationship.
Incorrect choices:
A: Determining the reason the client sought care is typically done in the initial phase of the relationship.
C: Discussing the client's new skill sets may be more appropriate in the termination phase where progress is reviewed.
D: Reviewing the client's demographic information is necessary but not a primary action during the working phase.