Nokea
A 72-year-old client is referred for counseling. During the initial nursing assessment, the client denies the need for counseling. The nurse would agree with the client if she made which of the following comments?
- A. My doctor just put me on an antidepressant, and I'll be fine in a week or so.'
- B. My daughter sent me here. She's mad because I don't have the energy to take care of my grandkids.'
- C. Since I've gotten over the death of my husband, I've had more energy and been more active than before he died.'
- D. My son got worried because I made this silly comment about wanting to be with my husband in heaven.'
Correct Answer: C
Rationale: Increased energy and activity post-grief suggest the client is coping well, supporting her denial of needing counseling.
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A 6-year-old child is admitted with suspected appendicitis. Which symptom should the nurse prioritize when assessing this child?
- A. Fever
- B. Nausea
- C. Rebound tenderness
- D. Diarrhea
Correct Answer: C
Rationale: Rebound tenderness in the right lower quadrant is a hallmark sign of appendicitis, indicating peritoneal irritation and requiring urgent surgical evaluation.
Which actions should the nurse implement to prevent ventilator-associated pneumonia (VAP) in the client who is intubated and on mechanical ventilation?
- A. Practice meticulous hand hygiene.
- B. Maintain the head of the bed elevation at 10 degrees.
- C. Perform suctioning of oral cavity secretions every 4 hours.
- D. Have the respiratory therapist change the ventilator circuit tubing every 4 hours.
Correct Answer: A
Rationale: Because normal upper airway defenses are bypassed, clients who are intubated with mechanical ventilation are at risk for VAP. Prevention includes effective hand washing before and after suctioning, when touching ventilator equipment, and when in contact with respiratory secretions. To prevent aspiration of colonized secretions from the oral cavity, the client will need more frequent oral cavity suctioning and at least 30 degrees head of the bed elevation. The more frequently the circuit is broken, the greater the risk for pathogen entry.
A client with a history of seizures is prescribed phenytoin (Dilantin). The nurse should instruct the client to report which of the following side effects?
- A. Gingival hyperplasia.
- B. Weight gain.
- C. Insomnia.
- D. Dry skin.
Correct Answer: A
Rationale: Phenytoin commonly causes gingival hyperplasia, which should be reported to manage oral health and adjust treatment if needed.
You are working in a community pediatric health clinic. Which expected life transition should you apply into your practice for these pediatric clients as you are caring for pediatric clients of all ages?
- A. Pregnancy
- B. Puberty
- C. Childhood immunizations
- D. Separation anxiety
Correct Answer: B
Rationale: Puberty is a significant life transition for pediatric clients, particularly adolescents, and is relevant across the age range in a pediatric clinic. It involves physical, emotional, and social changes that nurses should consider in their practice.
The nurse is caring for a client who is being treated with an intravenous (IV) bolus of lidocaine hydrochloride. What should the nurse monitor when considering the actions and the effects of this medication?
- A. Urinary pH
- B. Radial pulse
- C. Temperature
- D. Blood pressure
Correct Answer: D
Rationale: Lidocaine hydrochloride is an antidysrhythmic medication used to treat ventricular dysrhythmias. It can cause hypotension as a side effect, so monitoring blood pressure is critical to assess for adverse effects and ensure client safety. Urinary pH, radial pulse, and temperature are not directly related to the primary actions or adverse effects of lidocaine.