Nokea
A client in labor with a history of a previous cesarean birth has chosen to attempt a vaginal birth. During labor, which finding would be most concerning to the nurse?
- A. Cessation of contractions and maternal tachycardia
- B. Fetal tachycardia with moderate variability
- C. Increased anxiety and discomfort with contractions
- D. Painful, strong contractions every 3-4 minutes
Correct Answer: A
Rationale: Cessation of contractions with maternal tachycardia (A) suggests uterine rupture, a life-threatening emergency in VBAC due to scar dehiscence. Fetal tachycardia (B) is concerning but less specific, anxiety (C) is expected, and regular contractions (D) are normal.
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The nurse is caring for a client with immune thrombocytopenic purpura. Which client statements indicate a need for further teaching? Select all that apply.
- A. I use a soft-bristle toothbrush and mild mouth rinse.
- B. I enjoy walking and wear nonskid footwear for safety.
- C. I use a safety razor and gentle shaving cream.
- D. I sometimes get constipated, so I have been taking docusate.
- E. I when I have a headache, I take over-the-counter ibuprofen.
Correct Answer: C,E
Rationale: ITP increases bleeding risk. Using a safety razor (C) risks cuts, and ibuprofen (E) inhibits platelets, both requiring further teaching. Soft toothbrush (A), safe walking (B), and docusate (D) are appropriate.
A client admitted with glaucoma is being treated with miotic (pilocarpine) eye drops. Following administration of the medication, the nurse will note:
- A. Dilation of the pupils
- B. Diminished redness of the sclera
- C. Decreased edema of the cornea
- D. Constriction of the pupils
Correct Answer: D
Rationale: Miotics, such as pilocarpine, are administered to the client with glaucoma to cause pupillary constriction, thereby lowering intraocular pressure. Answer A is incorrect because miotics constrict the pupil. Answer B is incorrect because miotics do not diminish redness. Answer C is incorrect because miotics do not decrease edema of the cornea.
The nurse is caring for a client with schizophrenia who is experiencing visual hallucinations. The client states, 'There is a bad person standing in my room.' Which of the following responses would be most appropriate for the nurse to make?
- A. Your illness is making you experience visual hallucinations.'
- B. I know you are frightened, but I do not see anyone in your room.'
- C. Do not worry. I will give you medication that will make the bad person go away.'
- D. We will go into the dayroom and play a game. I know you like to play board games.'
Correct Answer: B
Rationale: When addressing hallucinations, the nurse should acknowledge the client’s fear while gently reinforcing reality. Response B validates the client’s emotions and clarifies that the nurse does not see the hallucination, maintaining trust without reinforcing the delusion. Labeling the hallucination as part of the illness (A) may confuse or alienate the client. Promising medication will resolve it (C) oversimplifies treatment, and distracting with games (D) dismisses the client’s distress.
A client with poorly controlled diabetes mellitus gives birth to a newborn at term gestation. When caring for the 2 hour-old newborn, which clinical finding requires the nurse to intervene?
- A. Cyanosis of hands and feet
- B. Heart rate of 165/min while crying
- C. Jitteriness
- D. Respirations of 60/min
Correct Answer: C
Rationale: Jitteriness (C) in a newborn of a diabetic mother suggests hypoglycemia, a common complication due to maternal hyperglycemia causing fetal hyperinsulinism. Immediate intervention (e.g., glucose testing) is needed. Acrocyanosis (A) is normal, heart rate 165/min while crying (B) is within range, and respirations of 60/min (D) are normal for a newborn.
A person who has psoriasis is seen in the clinic. The lesions are covered with coal tar. Which instruction should the nurse give the client?
- A. Call if you have nausea and vomiting.'
- B. Protect the area from sunlight for 24 hours.'
- C. Wash off the solution after six to eight hours.'
- D. Call if your skin looks dark during the treatment.'
Correct Answer: B
Rationale: Coal tar increases photosensitivity; protecting the area from sunlight for 24 hours prevents burns. Nausea, washing off, or skin darkening are not primary concerns.