Nokea
A 16-year-old young woman is brought by her parents to the outpatient clinic for treatment of pelvic inflammatory disease (PID). While the nurse obtains a history, the client says bitterly, 'My parents are mean and don't really care about me.' Which of the following responses by the nurse is BEST?
- A. You feel your parents don't care about you?
- B. Your parents brought you to the clinic, didn't they?
- C. I am sure that your parents have your best interests at heart.
- D. Did you have a disagreement with your parents?
Correct Answer: A
Rationale: Reflecting the client’s feelings validates her emotions, encouraging therapeutic communication. Options B, C, and D are nontherapeutic, dismissing or challenging her statement.
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A child who received meperidine (Demerol) IM one hour ago.
The nurse knows that which of the following is the BEST assessment indicating relief from abdominal pain for a child who received meperidine (Demerol) IM one hour ago?
- A. The child states that his pain has gone away.
- B. The child's heart rate has changed from 80 to 95.
- C. The child sleeps except when receiving nursing care.
- D. Results from the incentive spirometer have improved.
Correct Answer: D
Rationale: Strategy: Think about what the words mean. (1) contains correct information, but is not a priority; child could deny pain out of fear of getting another injection (2) indicates discomfort, anxiety (3) indicates a need to decrease the amount of medication (4) correct-when pain is decreased, child will be better able to breathe deeply and improve the outcome of use of the incentive spirometer
An alert adult who has terminal cancer says to the home care nurse, 'When the time comes for me to go, I don't want to be in pain and I don't want you to try to resuscitate me. Please promise me you won't.' How should the nurse respond?
- A. Of course, I will do as you wish.
- B. I am obligated to try and preserve life.
- C. Do you have advance directives? These need to be in your record.
- D. Be sure to tell each nurse your desires.
Correct Answer: C
Rationale: Asking about advance directives ensures the client's wishes are documented and legally binding, facilitating appropriate end-of-life care.
The physician has ordered insertion of a nasogastric tube to provide supplemental feedings for a client recovering from a stroke. To facilitate insertion of the nasogastric tube, the nurse should:
- A. Offer the client ice chips to swallow as the tube is advanced.
- B. Tell the client to flex his neck on his chest.
- C. Tell the client to hyperextend his neck.
- D. Place the tube in warm water.
Correct Answer: B
Rationale: Flexing the neck aligns the esophagus, facilitating nasogastric tube insertion. Ice chips increase choking risk. Hyperextension misaligns the airway. Warm water is ineffective.
The nurse is caring for a client with a history of asthma who is receiving montelukast (Singulair) 10 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I take my medication at night.
- B. I have a headache sometimes.
- C. I feel sad and hopeless.
- D. I use my albuterol inhaler when I wheeze.
Correct Answer: C
Rationale: Feeling sad and hopeless suggests depression, a rare but serious side effect of montelukast, requiring immediate evaluation. Options A, B, and D are less concerning: nighttime dosing is standard, headaches are nonspecific, and albuterol use is appropriate.
The client is scheduled for a myelogram today. The permit has been signed. The client tells the nurse that she has changed her mind and does not want to have the procedure. What should the nurse do?
- A. Tell the client that once permission has been given, the procedure has to be done
- B. Tell the client that the physician will be very upset if she does not have it done
- C. Suggest to the client that it is in her best interests to have the procedure as scheduled
- D. Understand that the client has the right to change her mind about procedures
Correct Answer: D
Rationale: Clients have the right to withdraw consent at any time, respecting autonomy. Coercion or suggesting physician displeasure is unethical.