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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A 15-month-old continually turns his cup upside down and shakes milk from the spout. The mother is convinced that he does this on purpose and asks the nurse what she should do. The nurse's response should be guided by the knowledge that:
- A. Toddlers often misbehave to get the attention of adults.
- B. Toddlers are able to use thought processes to experience events and reactions.
- C. Negative actions that are not immediately punished will be repeated.
- D. Manipulation of objects in their environment enables the toddler to learn about spatial relationships.
Correct Answer: D
Rationale: Toddlers explore spatial relationships through actions like shaking a cup, not necessarily to misbehave. Attention-seeking or punishment is less relevant.
The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
- A. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
- B. The nurse loosely suspends the client's arm in an open hand while tapping the back of the client's elbow.
- C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
- D. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.
Correct Answer: A
Rationale: To elicit the biceps reflex, the nurse places her thumb on the biceps tendon in the antecubital space and taps it with a reflex hammer, so A is correct. Answer B is incorrect as it describes a different technique. Answer C refers to the patellar reflex, and Answer D is not a standard method for the biceps reflex.
While assisting a client with AM care, the nurse notes small elevated skin lesions less than $0.5 \mathrm{cm}$ in diameter over the client's back. The nurse should describe the lesions as:
- A. Macules
- B. Plaques
- C. Wheals
- D. Papules
Correct Answer: D
Rationale: Papules are small, elevated skin lesions less than 0.5 cm in diameter, matching the description provided.
The day shift nurse provides handoff of care report to the oncoming night shift nurse. Which of the following statements by the nurse are appropriate to include in the report? Select all that apply.
- A. I gave acetaminophen 500 mg PO to the client for a headache, with good relief.
- B. The client had morphine 15 mg PO 45 minutes ago for leg pain and now reports 3 on a pain scale of 0-10.
- C. The client's sisters visited today and were very rude, but they did bring the client's medication list.
- D. The continuous bladder irrigation normal saline infusion bag will need to be replaced at 9 PM.
- E. The radiology department called to say that an ultrasound will be performed at 9 PM.
Correct Answer: A,B,D,E
Rationale: Acetaminophen administration (A), morphine effect (B), irrigation replacement (D), and ultrasound schedule (E) are relevant to care. Family behavior (C) is subjective and inappropriate.
The nurse is caring for a client with syndrome of inappropriate antidiuretic hormone. Which of the following actions should the nurse take? Select all that apply.
- A. Administer vasopressin.
- B. Implement seizure precautions.
- C. Perform frequent neurological checks.
- D. Keep a strict record of fluid intake and output.
- E. Maintain an IV infusion of 0.9% sodium chloride.
Correct Answer: B,C,D
Rationale: Seizure precautions (B), neurological checks (C), and strict I&O (D) manage SIADH complications like hyponatremia. Vasopressin (A) worsens SIADH, and normal saline (E) may not correct hyponatremia.