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A client has recently lost her best friend to cancer. The client tells the nurse, 'I'm very sad about the loss of my friend.' Which of the following responses by the nurse is the most appropriate?
- A. I lost my best friend two years ago, but I feel better now.
- B. It's important for you to keep busy.
- C. Why do you feel this way?
- D. It's normal to feel loss. Tell me about your friend.
Correct Answer: D
Rationale: This response validates the client’s grief and encourages her to share, promoting therapeutic communication and emotional support.
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A child with achondroplasia will likely have which of the following physical characteristics?
- A. alopecia, failure to thrive, small face, recessed jaw
- B. enlarged hands and feet, skull expansion at fontanelle, enlarged tongue
- C. poor muscle tone, slanted eyes, single palmar crease
- D. dwarf stature, short fingers and toes, short proximal limbs
Correct Answer: D
Rationale: Achondroplasia causes dwarfism, short fingers/toes, and short proximal limbs due to impaired cartilage growth.
A gravida II para 0 is admitted to the labor and delivery unit. The doctor performs an amniotomy. Which observation would the nurse expect to make immediately after the amniotomy?
- A. Fetal heart tones 160 beats per minute
- B. A moderate amount of clear fluid
- C. A small amount of greenish fluid
- D. A small segment of the umbilical cord
Correct Answer: B
Rationale: A moderate amount of clear amniotic fluid is expected after an amniotomy, indicating normal rupture of membranes.
A client with preeclampsia has been receiving an infusion containing magnesium sulfate for a blood pressure that is 160/80; deep tendon reflexes are 1 plus, and the urinary output for the past hour is 100 mL. The nurse should:
- A. Continue the infusion of magnesium sulfate while monitoring the client's blood pressure
- B. Stop the infusion of magnesium sulfate and contact the physician
- C. Slow the infusion rate and turn the client on her left side
- D. Administer calcium gluconate IV push and continue to monitor the blood pressure
Correct Answer: A
Rationale: The parameters (BP 160/80, 1+ reflexes, 100 mL urine output) are within acceptable limits, so the infusion should continue.
Which symptom is not associated with glaucoma?
- A. Veil-like loss of vision
- B. Foggy loss of vision
- C. Seeing halos around lights
- D. Complaints of eye pain
Correct Answer: A
Rationale: Veil-like loss of vision is not typical of glaucoma; foggy vision, halos, and eye pain are common symptoms.
The nurse is performing an assessment of an elderly client with a total hip repair. Based on this assessment, the nurse decides to medicate the client with an analgesic. Which finding most likely prompted the nurse to decide to administer the analgesic?
- A. The client's blood pressure is 130/86.
- B. The client is unable to concentrate.
- C. The client's pupils are dilated.
- D. The client grimaces during care.
Correct Answer: D
Rationale: Grimacing during care indicates pain, prompting the nurse to administer an analgesic.