Nokea
A 42-year-old client with breast cancer is concerned that her husband is depressed by her diagnosis. Which of the following changes in her husband's behavior may confirm her fears?
- A. Increased decisiveness.
- B. Problem-focused coping style.
- C. Increase in social interactions.
- D. Disturbance in his sleep patterns.
Correct Answer: D
Rationale: Sleep disturbances are a common symptom of depression, suggesting the husband may be struggling emotionally with his wife's diagnosis.
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The nurse administers a bolus tube feeding to a client with cancer. Which of the following nursing interventions is most appropriate to decrease the risk of aspiration?
- A. Place the client on bed rest with the head of the bed elevated to 60 degrees for 2 hours.
- B. Place the client on the left side with the head of the bed at 45 degrees for 15 minutes.
- C. Assist the client out of bed to sit upright in a chair for 1 hour.
- D. Ask the client to rest in bed with the head of the bed elevated to 30 degrees for 20 minutes.
Correct Answer: C
Rationale: Sitting upright in a chair for 1 hour after a bolus tube feeding minimizes aspiration risk by promoting gastric emptying and reducing reflux.
A client with a surgical wound reports itching around the incision site on postoperative day 5. The nurse should:
- A. Apply an antihistamine cream.
- B. Assess the wound for signs of infection.
- C. Instruct the client to avoid scratching.
- D. Clean the wound with alcohol.
Correct Answer: C
Rationale: Itching is common during healing, but scratching can disrupt the incision. Instructing the client to avoid scratching prevents wound dehiscence while further assessment can rule out infection.
Following a total hip replacement, the nurse should do which of the following? Select all that apply.
- A. With the aid of a coworker, turn the client from the supine to the prone position every 2 hours.
- B. Encourage the client to use the overhead trapeze to assist with position changes.
- C. For meals, elevate the head of the bed to 90 degrees.
- D. Use a fracture bedpan when needed by the client.
- E. When the client is in bed, prevent thromboembolism by applying thigh-high antiembolism stockings.
Correct Answer: B,D,E
Rationale: Using a trapeze, fracture bedpan, and antiembolism stockings supports recovery and prevents complications. Prone positioning and 90-degree elevation risk dislocation.
A client has had hoarseness for more than 2 weeks. The nurse should:
- A. Refer to a health care provider for a prescription for an antibiotic.
- B. Instruct the client to gargle with salt water at home.
- C. Assess the client for dysphagia.
- D. Instruct the client to take a throat analgesic.
Correct Answer: C
Rationale: Persistent hoarseness may indicate laryngeal pathology, including cancer; assessing for dysphagia (difficulty swallowing) helps evaluate severity and urgency. Antibiotics are inappropriate without a bacterial diagnosis. Gargling or analgesics may mask symptoms without addressing the cause.
The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician?
- A. The client's daily record indicates a 3 kg weight loss in 2 days.
- B. The client is complaining of nausea.
- C. The client has a temperature of 99°F orally.
- D. The client has fatigue.
Correct Answer: A
Rationale: A 3 kg weight loss in 2 days (A) is significant and may indicate worsening liver function or fluid loss, requiring urgent physician attention. Nausea (B), low-grade fever (C), and fatigue (D) are common but less critical.