Nokea
A client delivered a stillborn male at term. An appropriate action of the nurse would be to:
- A. State, 'You have an angel in heaven.'
- B. Discourage the parents from seeing the baby.
- C. Provide an opportunity for the parents to see and hold the baby for an undetermined amount of time.
- D. Reassure the parents that they can have other children.
Correct Answer: C
Rationale: This is not a supportive statement. There are also no data to indicate the family's religious beliefs. Seeing their baby assists the parents in the grieving process. This gives them the opportunity to say 'good-bye.' Parents need time to get to know their baby. This is not a comforting statement when a baby has died. There are also no guarantees that the couple will be able to have another child.
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A 45-year-old male client was admitted to a chemical dependency treatment center following legal problems related to alcohol abuse. He states, 'I know that alcohol is a problem for some people, but I can stop whenever I want to. I'm never sick or miss work, and no one can complain about me.' During the initial assessment, the best response by the nurse would be:
- A. The fact is you are an alcoholic or you wouldn't be here.
- B. I understand it took strength to admit yourself to the unit, and I will do my part to help you to stay alcohol-free.
- C. If you can stop drinking when you want to, why don't you stop?
- D. It's good that you can stop drinking when you want to.
Correct Answer: B
Rationale: Direct confrontation initially is nontherapeutic and may result in the client becoming frustrated and wanting to leave. A positive, supportive attitude builds trust, and identifying positive strength raises self-esteem. Offering help allows the client to feel that he is not alone in dealing with problems. Asking the client why or to give an explanation for his behavior puts him in a position of having to justify his behavior to the nurse. Giving approval or placing a value on feelings or a behavior may limit the client's freedom to behave in a way that may displease another. This response may lead to seeking praise instead of progress.
The client is admitted with a diagnosis of gestational diabetes. Which dietary recommendation is most appropriate?
- A. Low-carbohydrate,high-protein diet
- B. High-fat,low-calorie diet
- C. Low-protein,high-carbohydrate diet
- D. High-calorie,low-fat diet
Correct Answer: A
Rationale: A low-carbohydrate high-protein diet helps maintain stable blood glucose levels in gestational diabetes reducing the risk of hyperglycemia. High-fat high-carbohydrate or high-calorie diets are less suitable.
The RN on the oncology unit is preparing to mix and administer amphoteracin B (Fungizone) to a client. Which action is contraindicated for administering this drug IV?
- A. Mix the drug with normal saline solution.
- B. Administer the drug over 4-6 hours.
- C. Hydrate with IV fluids two hours before the infusion is scheduled to begin.
- D. Premedicate the client with ordered acetaminophen (Tylenol) and diphenhydramine (Benadryl).
Correct Answer: A
Rationale: Amphotericin B should be mixed with D5W, not normal saline, due to stability issues. Slow infusion (B), hydration (C), and premedication (D) are standard practices.
A client's congestive heart failure has been treated, and he will soon be discharged. Discharge teaching should include instruction to call the physician if he notices a 2-lb weight gain in a 24-hour period. Increased weight gain may indicate:
- A. A diet too high in calories and saturated fat
- B. Decreasing cardiac output
- C. Decreasing renal function
- D. Development of diabetes insipidus
Correct Answer: B
Rationale: A 2-lb weight gain in 24 hours suggests fluid retention due to decreasing cardiac output, activating the renin-angiotensin-aldosterone system.
A client who has been diagnosed with anorexia nervosa refuses to eat lunch. The most therapeutic response by the nurse to her refusal is:
- A. Okay, missing one meal won't hurt.'
- B. You'll have to eat lunch, or we'll force-feed you.'
- C. It's not appropriate for you to try to manipulate the staff into granting your wishes.'
- D. We will not allow you to starve yourself. You may choose to eat voluntarily or be fed.'
Correct Answer: D
Rationale: Setting limits assures the client that staff has genuine concern for her safety and well-being. Giving her an actual choice will give the client an increased sense of control over her life and avoid an argument or power struggle.