Nokea
A 14-year-old client confides to the school nurse that she is pregnant, likely in the second trimester, and has not had prenatal care. Which of the following topics should the nurse discuss with the client at this time? Select all that apply.
- A. Desire for adoption planning services
- B. Emotional response to the pregnancy
- C. Family/social support systems
- D. Nutritional habits and substance use
- E. Plan for finishing high school
Correct Answer: A,B,C,D,E
Rationale: All topics are critical: adoption planning, emotional response, support systems, nutrition/substance use, and education planning address the client’s immediate and long-term needs in a sensitive, holistic manner.
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The nurse is talking with a client who has breast cancer and is receiving tamoxifen. Which of the following statements by the client would require immediate follow-up?
- A. I have been experiencing frequent hot flashes
- B. I have been experiencing vaginal dryness
- C. I have had a decreased interest in sexual intercourse
- D. I have noticed that my menses are heavy
Correct Answer: D
Rationale: Heavy menses while on tamoxifen may indicate endometrial hyperplasia or cancer, a serious side effect requiring immediate evaluation. Hot flashes, vaginal dryness, and decreased libido are common, less urgent side effects.
A nurse is asked to float to the telemetry unit because the unit is short-staffed. The nurse is not familiar with this client population and is concerned about providing safe client care. What is the best action by the nurse?
- A. Accept the assignment and ask about what skills need to be performed
- B. Ask the nurse supervisor if a more experienced nurse can go instead
- C. Read the policy and procedure book for the unit before providing care
- D. Refuse to float to the unit because of concerns about client safety
Correct Answer: A
Rationale: Accepting the assignment and clarifying required skills ensures safe care with support, addressing concerns proactively. Refusing or deferring may disrupt staffing, and reading policies delays care.
The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?
- A. Skin irritation
- B. Drug tolerance
- C. Severe headaches
- D. Postural hypotension
Correct Answer: B
Rationale: Drug tolerance. Removing a nitroglycerine patch for a period of 10-12 hours daily prevents tolerance to the drug, which can occur with continuous patch use.
The nurse in the mental health unit is observing staff members communicating with assigned clients. Which of the following statements by a staff member to a client would require the nurse to intervene?
- A. I do not understand what you mean. Can you give me an example?
- B. I understand that you believe the government is out to get you
- C. If you feel comfortable, could you elaborate on how your child died?
- D. Why did you get so angry when your spouse ignored you?
Correct Answer: D
Rationale: Asking 'why' can seem judgmental and provoke defensiveness, hindering therapeutic communication. Seeking clarification, acknowledging beliefs, and inviting elaboration are appropriate and supportive.
A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is
- A. Transparent film dressing
- B. Wet dressing with debridement granules
- C. Wet to dry with hydrogen peroxide
- D. Moist saline dressing
Correct Answer: D
Rationale: Moist saline dressing. A stage III pressure ulcer with granulation tissue requires a moist environment to promote healing.