Nokea
A 14-year old with leukemia tells the nurse, 'All I really want to eat is frozen yogurt.' The nurse should:
- A. Explain the importance of eating a balanced diet
- B. Ask the dietician to talk with the client to find out which foods he prefers
- C. Ask the kitchen to send the yogurt
- D. Document the client's refusal to eat the diet as ordered
Correct Answer: C
Rationale: Providing the requested yogurt respects the client's preferences and encourages intake, which is critical in leukemia patients who may have reduced appetite.
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A client recovering at home following a left total knee replacement 7 days ago is using a cane to go up and down the stairs under the supervision of the home health nurse. Which client action indicates a need for reinforcement of teaching?
- A. Faces forward when going up and down the stairs
- B. Holds the cane with the right hand
- C. Leads with left leg, follows next with cane, and finally right leg when going up the stairs
- D. Places full weight on left leg when going down the stairs
Correct Answer: D
Rationale: Placing full weight on the surgical leg when going down stairs risks injury and instability. The client should lead with the cane and unaffected leg, using the surgical leg cautiously.
An older adult is seen in clinic. During the assessment process, all of the following are expressed or noted. Which is of most immediate concern to the nurse?
- A. The client's daughter says that the client has become increasingly forgetful.
- B. The client has a productive cough.
- C. The client ambulates slowly.
- D. The client says, 'My arms aren't long enough for me to read the paper.'
Correct Answer: B
Rationale: A productive cough suggests a respiratory infection, potentially serious in an older adult, requiring immediate evaluation. Forgetfulness, slow ambulation, or presbyopia are less urgent.
A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should
- A. Administer a placebo
- B. Encourage increased fluid intake
- C. Administer the prescribed analgesia
- D. Recommend relaxation exercises for pain control
Correct Answer: C
Rationale: Administer the prescribed analgesia. Pain relief is a priority in sickle cell crisis, and prescribed analgesics are appropriate.
The nurse is caring for a client with cirrhosis who has ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which of the following actions should the nurse take? Select all that apply.
- A. Assist the client to ambulate in the hallway every shift
- B. Encourage the client to increase sodium intake
- C. Maintain the client in semi-Fowler position
- D. Provide an alternating air pressure mattress for the client
- E. Use music to provide a distraction for the client
Correct Answer: C,D,E
Rationale: Semi-Fowler position helps alleviate shortness of breath by reducing pressure on the diaphragm. An alternating air pressure mattress reduces the risk of pressure injuries due to immobility. Music can help reduce discomfort and anxiety, providing a non-pharmacological distraction.
The nurse has been interacting for several weeks with a client on the psychiatric unit. The nurse is to be transferred to another unit. Which comment by the client indicates separation anxiety?
- A. We had a good time at the party last night. You should have been here.'
- B. Some of us are going to the museum next week. Too bad you can't go.'
- C. I was thinking about my friend last night; the one who died in the car crash.'
- D. I was telling my wife what a good nurse you are.'
Correct Answer: B
Rationale: Expressing regret about the nurse missing a future event suggests attachment and anxiety about the nurse's departure, indicating separation anxiety. Other comments lack this emotional connection.