Nokea
A 15-year-old client is admitted to the adolescent unit. The nurse recognizes that encouraging a client to speak openly depends on how clearly questions are phrased. Which of the following statements is most desirable in eliciting information from an adolescent client?
- A. Do you get along well with your family?'
- B. Do you communicate with your parents?'
- C. You don't hate your family, do you?'
- D. What is it like between you and your family?'
Correct Answer: D
Rationale: (A, B) This statement can be answered with a simple yes or no. This statement is asked in a negative manner and therefore has a negative connotation. This statement is open ended and positively stated.
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The nurse is teaching a client with a history of fibromyalgia about self-care. The nurse should tell the client to:
- A. Engage in regular exercise
- B. Avoid all physical activity
- C. Increase caffeine intake
- D. Use heating pads excessively
Correct Answer: A
Rationale: Regular, low-impact exercise can reduce pain and stiffness in fibromyalgia, improving overall function and well-being.
A female client has been hospitalized for several months following major abdominal surgery for a ruptured colon. A colostomy was created, and the large abdominal wound was left open and allowed to heal through granulation. She is receiving gentamicin IV for treatment of wound infection. Knowing this drug is ototoxic, the nurse would implement which of the following measures?
- A. Instruct the client to report any signs of tinnitus, dizziness or difficulty hearing.
- B. Advise the client to discontinue the drug at the first sign of dizziness.
- C. Order audiometric testing in order to determine if hearing loss is caused by an ototoxic drug or other cause.
- D. Instruct the client in Valsalva's maneuver to equalize middle ear pressure and to prevent hearing loss.
Correct Answer: A
Rationale: The first nursing measure is to instruct the client in which drug side effects to report. Discontinuing the drug is not an independent nursing intervention and may compromise client care. Audiometric testing will detect hearing loss, but it does not indicate a potential cause. Equalizing middle ear pressure will not prevent hearing loss.
A client with a history of a tonsillectomy is being discharged. The nurse should teach the client to:
- A. Gargle with warm salt water
- B. Avoid cold liquids
- C. Report excessive swallowing
- D. Use a straw for fluids
Correct Answer: C
Rationale: Excessive swallowing post-tonsillectomy may indicate bleeding, a serious complication requiring immediate reporting. Gargling, cold liquids, and straws may irritate the surgical site.
The nurse is assessing a client with suspected deep vein thrombosis (DVT). Which finding is most indicative?
- A. Bilateral leg edema
- B. Warm, red, swollen calf
- C. Mild leg cramping
- D. Pale, cool foot
Correct Answer: B
Rationale: A warm, red, swollen calf is a classic sign of DVT due to clot-related inflammation. Bilateral edema (A) suggests heart failure, cramping (C) is nonspecific, and pale/cool foot (D) indicates arterial occlusion.
The registered nurse is making shift assignments. Which client should be assigned to the licensed practical nurse (LPN)?
- A. A client who is a diabetic with a foot ulcer
- B. A client with a deep vein thrombosis receiving intravenous heparin
- C. A client being weaned from a tracheostomy
- D. A post-operative cholecystectomy with a T-tube
Correct Answer: A
Rationale: A diabetic with a foot ulcer is stable and suitable for an LPN, who can perform wound care and monitoring. Heparin infusion (B), tracheostomy weaning (C), and T-tube management (D) require RN-level skills due to complexity and risk.