Nokea
A client with paranoid thoughts refuses to eat because of the belief that the food is poisoned. The appropriate statement at this time for the nurse to say is
- A. Here, I will pour a little of the juice in a medicine cup to drink it to show you that it is OK.'
- B. The food has been prepared in our kitchen and is not poisoned.'
- C. Let's see if your partner could bring food from home.'
- D. If you don't eat, I will have to suggest for you to be tube fed.'
Correct Answer: C
Rationale: Reassurance is ineffective when a client is actively delusional. This option avoids both arguing with the client and agreeing with the delusional premise.
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During the interview of a prospective employee who just completed the agency orientation, which approach would be the best for the nurse manager to use to assess competence?
- A. What degree of supervision for basic care do you think you need?
- B. Let's review your skills check-list for type and level of skill
- C. Are you comfortable working independently?
- D. What client care tasks or assignments do you prefer?
Correct Answer: B
Rationale: The nurse needs to know that the employee has competence in certain tasks. One way to do this is to do mutual review of documented skills.
The nurse employed in a woman's health care clinic would be most concerned about which client statement?
- A. I recently noticed a small, round, painless, mobile lump in my left breast while showering.
- B. Last night while breastfeeding, my nipples were cracked and my breasts were painful.
- C. My right breast is red and warm with little tiny indented areas on the surface of the skin.
- D. Sometimes during my cycle, I notice breast nodules that are movable and feel soft to the touch.
Correct Answer: C
Rationale: Red, warm breast with indented skin suggests inflammatory breast cancer, requiring urgent evaluation. A mobile lump is often benign, nipple pain is common in breastfeeding, and cyclic nodules are typically hormonal.
The nurse is caring for a client who has been started on sulfamethoxazole/trimethoprim for a urinary tract infection. It is most important for the nurse to follow up on which client statement?
- A. I go to the bathroom a lot more than usual
- B. It burns when I pee.
- C. My urine is cloudy
- D. There is a red rash on my abdomen.
Correct Answer: D
Rationale: A rash may indicate an allergic reaction, requiring urgent follow-up. Frequent urination , burning , and cloudy urine are UTI symptoms.
The nurse has received a prescription from the health care provider to administer 94 mg of methylprednisolone via IV push. The available vial contains 125 mg in 2 mL. Select the syringe containing the appropriate amount of medication to be administered.
- A. 1
- B. 2
- C. 3
- D. 4
Correct Answer: C
Rationale: Calculate: 94 mg ÷ 125 mg/2 mL = 1.504 mL. Syringe 3 (typically 1.5 mL) is closest. Syringes 1, 2, and 4 are not specified but assumed incorrect volumes.
A hospitalized client with thyrotoxicosis receives atenolol 50 mg PO daily. Which statement by the nurse accurately reinforces the client's understanding of this medication's purpose?
- A. Atenolol is an iodine-based medication that blocks the release of thyroid hormones.
- B. It is used to treat some of the symptoms of hyperthyroidism, such as increased heart rate.
- C. This medication is radioactive and damages or destroys the thyroid tissue.
- D. This first-line antithyroid drug inhibits the synthesis of thyroid hormones
Correct Answer: B
Rationale: Atenolol is a beta-blocker that controls hyperthyroidism symptoms like tachycardia. It is not iodine-based , radioactive , or an antithyroid drug .