Nokea
A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client is using the mechanism of 'suppression'?
- A. I don't remember anything about what happened to me.
- B. I'd rather not talk about it right now.
- C. It's all the other guy's fault! He was going too fast.
- D. My mother is heartbroken about this.
Correct Answer: A
Rationale: I don't remember anything about what happened to me. Suppression is willfully putting an unacceptable thought or feeling out of one's mind, used to protect one's self-esteem.
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A client who is receiving hydralazine (Apresoline) q6h has a blood pressure of 90/60.
Which of the following nursing actions would be MOST appropriate?
- A. Withhold the medication.
- B. Check the urinary output.
- C. Administer the medication.
- D. Increase the potassium intake.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? No. Determine the outcome of the implementations. (1) correct-BP of 90/60 is too low for an additional dose of medication, withholding the medication and checking with the doctor is appropriate (2) assessment, appropriate nursing action for a client on an antihypertensive that has diuretic effects due to increased blood flow to the kidney, not a priority in this instance (3) unnecessary (4) appropriate nursing action for a client on an antihypertensive that has diuretic effects due to increased blood flow to the kidney, not a priority in this instance
You are teaching a client about the patient controlled analgesia (PCA) planned for post-operative care. Which statement indicates further teaching may be needed by the client?
- A. I will be receiving continuous doses of medication.
- B. I should call the nurse before I take additional doses.
- C. I will call for assistance if my pain is not relieved.
- D. The machine will prevent an overdose.
Correct Answer: B
Rationale: Patient controlled analgesia offers the client more control. The client should be instructed to initiate additional doses as needed without asking for assistance unless there is insufficient control of the pain.
Because a client is taking rifampin (Rimactane), what must the nurse include when discussing medications with the client?
- A. Report any changes in hearing immediately because this is a common side effect.
- B. You should be taking vitamin B6 to prevent painful neuritis.
- C. If your big toes become painful, you must tell the physician.
- D. Your perspiration and urine may turn red-orange.
Correct Answer: D
Rationale: Rifampin commonly causes red-orange discoloration of urine and sweat, a harmless side effect clients should be informed about to avoid alarm.
At a health-screening clinic, an adult male client's total plasma cholesterol level is 200 mg/dL. The nurse should
- A. advise the client to decrease intake of fatty foods.
- B. schedule the client for a follow-up clinic visit in one month.
- C. inform the client that the cholesterol level is within normal limits.
- D. report the finding to the physician immediately.
Correct Answer: A
Rationale: A cholesterol level of 200 mg/dL is borderline high; reducing fatty foods is appropriate. Options B, C, and D are less immediate or incorrect.
The nurse is caring for a client with a history of type 2 diabetes who is receiving sitagliptin (Januvia) 100 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Upper abdominal pain.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Upper abdominal pain may indicate pancreatitis, a serious sitagliptin side effect. Options A, C, and D are less urgent.