Nokea
A 42-year-old client on an inpatient psychiatric unit comments that he was brought to the hospital by his wife because he had taken too many pills and states, 'I just couldn't take it anymore.' The nurse's best response to this disclosure would be:
- A. You shouldn't do things like that, just tell someone you feel bad.
- B. Tell me more about what you couldn't take anymore.
- C. I'm sure you probably didn't mean to kill yourself.
- D. How long have you been in the hospital?
Correct Answer: B
Rationale: Disapproving gives the impression that the nurse has a right to pass judgment on the client's thoughts, actions, or ideas. Giving a broad opening gives the client encouragement to continue with verbalization. Failing to acknowledge the client's feelings conveys a lack of understanding and empathy. Changing the subject takes the conversation away from the client and is indicative of the nurse's anxiety or insensitivity.
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The nurse is caring for the client who has been in a coma for two months. He has signed a donor card, but the wife is opposed to the idea of organ donation. How should the nurse handle the topic of organ donation with the wife?
- A. Tell the wife that the hospital will honor her wishes regarding organ donation, but contact the organ-retrieval staff.
- B. Tell her that because her husband signed a donor card, the hospital has the right to take the organs upon the death of her husband.
- C. Explain that it is necessary for her to donate her husband's organs because he signed the permit.
- D. Refrain from talking about the subject until after the death of her husband.
Correct Answer: D
Rationale: Discussing organ donation with the wife while the client is still alive may cause distress, especially given her opposition. The nurse should refrain from raising the topic until after the client’s death, respecting her emotional state and hospital policy, which typically involves organ donation teams post-mortem.
A seventh grader lost consciousness after being hit in the head with a basketball. In the emergency room his vital signs are stable, and he demonstrates no neurologic deficit. He will not be admitted to the hospital. It is most important that you advise his mother to:
- A. Encourage him to drink plenty of fluids
- B. Expect him to have nausea with vomiting
- C. Keep him awake for the next 12 hours
- D. Wake him up every 1-2 hours during the night
Correct Answer: D
Rationale: If the child cannot be awakened from sleep after head injury, it is an indication of serious increase in ICP. The mother should call an ambulance right away.
The serial sevens test is often used to determine delirium and dementia. This test aids in assessing which of the following?
- A. Abstract thinking
- B. Ability to focus and concentrate thoughts
- C. Judgment
- D. Memory
Correct Answer: B
Rationale: This answer is incorrect. The test measures the abilities to concentrate and calculate. The use of proverbs is the most common way to test abstraction. This answer is correct. The serial sevens test is a common test of calculation ability. It is difficult for the demented or delirious client to perform. This answer is incorrect. The test for judgment should predict whether the individual will behave in a socially accepted manner. This answer is incorrect. In testing memory, the nurse would attempt to get the client either to recall recent events or to think about past events.
A client with a history of chronic kidney disease is admitted with complaints of edema. The nurse should expect the client to have:
- A. Hypernatremia
- B. Hyponatremia
- C. Hyperkalemia
- D. Hypokalemia
Correct Answer: C
Rationale: Chronic kidney disease impairs potassium excretion, leading to hyperkalemia, which can cause cardiac complications.
A primipara is assessed on arrival to the postpartum unit. The nurse finds her uterus to be boggy. The nurse's first action should be to:
- A. Call the physician
- B. Assess her vital signs
- C. Give the prescribed oxytocic drug
- D. Massage her fundus
Correct Answer: D
Rationale: The nurse should first implement independent and dependent measures to achieve uterine tone before calling the physician. Assessment of vital signs will not help to restore uterine atony, which is the priority need. Giving a prescribed oxytocic drug would be necessary if the uterus did not maintain tone with massage. Fundal massage generally restores uterine tone within a few moments and should be attempted first.