Nokea
A 9-year-old client has terminal cancer, but the parents do not want the child to know the prognosis. Over the past days, the child has started asking questions such as what dying is like and whether the child will die. Which of the following actions by the nurse is most appropriate?
- A. Encourage the parents to openly discuss the child's questions
- B. Notify the health care provider about the child's questions
- C. Remind the child that everyone is trying to help the child get better
- D. Tell the child to ask the parents the questions about death
Correct Answer: A
Rationale: Encouraging parental discussion supports the child's emotional needs and honesty. Notifying the provider , reassuring falsely , or redirecting avoid addressing the child's questions.
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After a prolonged surgical procedure, the client reports unilateral leg pain. Which client assessment finding is most concerning?
- A. Client rates leg pain as '7'
- B. Negative Homan sign
- C. Prominent varicose veins bilaterally
- D. Right calf is 4 cm larger than left calf
Correct Answer: D
Rationale: Calf asymmetry of 4 cm suggests deep vein thrombosis, a critical postoperative complication. Pain is nonspecific, negative Homan sign is unreliable, and varicose veins are less urgent.
A client, admitted to the unit because of severe depression and suicidal threats, is placed on suicidal precautions. The nurse should be aware that the danger of the client committing suicide is greatest
- A. during the night shift when staffing is limited
- B. when the client's mood improves with an increase in energy level
- C. at the time of the client's greatest despair
- D. after a visit from the client's estranged partner
Correct Answer: B
Rationale: Suicide potential is often increased when there is an improvement in mood and energy level. At this time ambivalence is often decreased and a decision is made to commit suicide.
The nurse is reinforcing discharge instructions to a client who has had coronary artery bypass grafting. Which teachings are correct? Select all that apply.
- A. No sexual activity for at least 6 weeks postoperatively
- B. Notify the health care provider (HCP) of redness, swelling, or drainage at the incision site
- C. Refrain from lifting objects weighing >5 lb (2.25 kg) until approved by the HCP
- D. Take a shower daily without soaking chest and leg incisions
- E. Use lotion on incision sites when changing dressing if the areas are dry
Correct Answer: B,C,D
Rationale: Reporting infection signs , weight restrictions , and daily showers are correct. Sexual activity can resume earlier if stable, and lotion is not routine.
An 80-year-old client is receiving amikacin, an aminoglycoside antibiotic, IVPB every 12 hours. Which of the following data obtained
by the practical nurse is most important to report to the registered nurse before the client receives the next dose?
- A. client reports tinnitus
- B. Blood pressure 104/60 mm Hg
- C. urine output of 400 mL since last dose
Correct Answer: A
Rationale: Tinnitus may indicate ototoxicity, requiring immediate reporting. Low BP and urine output are less urgent without context of medication.
The nurse is providing home care to a man who had a transsphenoidal hypophysectomy the day before yesterday. Which behavior by the client indicates a need for more teaching?
- A. He bends over to tie his shoes.
- B. He tells the nurse he takes a lot of pills every day.
- C. He ambulates daily.
- D. He tells the nurse he has ordered a medical identification bracelet.
Correct Answer: A
Rationale: Bending over increases intracranial pressure, risking cerebrospinal fluid leak post-hypophysectomy, indicating a need for further teaching on activity restrictions.