Nokea
A client has many delusions. As the nurse helps the client prepare for breakfast the client comments 'Don't waste good food on me. I'm dying from this disease I have.' The appropriate response would be
- A. You need some nutritious food to help you regain your weight.'
- B. None of the laboratory reports show that you have any physical disease.'
- C. Try to eat a little bit, breakfast is the most important meal of the day.'
- D. I know you believe that you have an incurable disease.'
Correct Answer: D
Rationale: This response does not challenge the client’s delusional system and thus forms an alliance by providing reassurance of desire to help the client.
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The nurse is observing a staff member talking with the parent of a pediatric client. The parent is crying and states, 'I do not know what to do about this situation with my child.' The staff member responds, 'I am sure you will do the right thing.' The nurse should recognize that the staff member's response
- A. expresses interest in the parent's concern
- B. demonstrates respect for the parent's privacy
- C. devalues the parent's feelings and gives false reassurance
- D. conveys empathy toward the parent and promotes self-confidence
Correct Answer: C
Rationale: The response (C) dismisses the parent's distress and provides false reassurance, lacking empathy. It does not express interest (A), respect privacy (B), or convey empathy (D).
The nurse is preparing to irrigate the wound of a 7-year-old client who sustained a laceration while on a playground. Which of the following actions should the nurse take? Select all that apply.
- A. Administer a prescribed analgesic 30 minutes before irrigating the wound
- B. Cleanse the wound from the most contaminated to the least contaminated area
- C. Obtain a 10-mL syringe and a 27-gauge needle
- D. Review the client's vaccination record
- E. Use continuous pressure to flush the wound and repeat until the drainage is clear
Correct Answer: A,D,E
Rationale: Analgesics (A), checking vaccinations (D) for tetanus risk, and continuous flushing (E) are appropriate. Cleaning from contaminated to clean (B) is incorrect, and a 27-gauge needle (C) is too small for irrigation.
The nurse is caring for a client with suspected acute rheumatic fever. Which of the following questions would be most important for the nurse to ask the client?
- A. Do you typically take all of your antibiotics when they are prescribed?
- B. Has anyone in your family had rheumatic fever?
- C. What has your temperature been over the past several days?
- D. Have you recently had a streptococcal throat infection?
Correct Answer: D
Rationale: Recent streptococcal infection (D) is the primary trigger for rheumatic fever, making it the most important question. Antibiotic compliance (A), family history (B), and fever (C) are relevant but less critical.
An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:
- A. check the carotid pulse
- B. deliver 5 abdominal thrusts
- C. give 2 rescue breaths
- D. ensure an open airway
Correct Answer: D
Rationale: According to the ABCs of CPR, the first step in rescuing an unresponsive victim after checking responsiveness and calling for help is to open the victim's airway.
A client with chronic heart failure calls the clinic to report a weight gain of 3 lb (1.4 kg) over the last 2 days. Which information is most important for the nurse to ask this client?
- A. Diet recall for this current week
- B. Fluid intake for the past 2 days
- C. Medications and dosages taken over the past 2 days
- D. Presence of shortness of breath, coughing, or edema
Correct Answer: D
Rationale: Symptoms like shortness of breath, coughing, or edema (D) indicate fluid overload, a critical concern in heart failure. Diet (A), fluid intake (B), and medications (C) are relevant but secondary.