Nokea
A client is admitted for removal of a goiter. Which nursing intervention should receive priority during the post-operative period?
- A. Maintaining fluid and electrolyte balance
- B. Assessing the client's airway
- C. Providing needed nutrition and fluids
- D. Providing pain relief with narcotic analgesics
Correct Answer: B
Rationale: A goiter is hyperplasia of the thyroid gland. Removal of a goiter can result in laryngeal spasms and airway occlusion. The other answers are lesser in priority.
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The school nurse is conducting an educational session for middle school teachers that is designed to heighten awareness of school bullying. The nurse recognizes that further instruction is needed when one of the teachers makes which comment?
- A. Bullying is a normal part of childhood growth and development.
- B. Children with physical disabilities are more vulnerable to bullying.
- C. Most children who are victims of a school bully do not tell an adult about it.
- D. The most common form of bullying is verbal aggression, such as insults and intimidation.
Correct Answer: A
Rationale: Bullying is not a normal part of development (A) and requires intervention. Vulnerability of disabled children (B), underreporting (C), and verbal aggression (D) are accurate.
The nurse assesses a client who has been re-admitted to the psychiatric inpatient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment?
- A. Stressors in the home
- B. Medication compliance
- C. Exposure to hot temperatures
- D. Alcohol use
Correct Answer: B
Rationale: Medication compliance. Ensuring adherence to fluphenazine is critical for symptom management in schizophrenia.
A client with a fractured hip asks the nurse about activity after discharge. The nurse should explain to the client that she should refrain from which of the following activities?
- A. Crossing her legs at the knee
- B. Sitting in a recliner
- C. Walking up stairs
- D. Carrying objects that weigh more than 10 pounds
Correct Answer: A
Rationale: Crossing legs at the knee can cause hip adduction, risking dislocation in a fractured hip. Other activities are generally safe with proper precautions.
The health care provider (HCP) explains the risks and benefits of a procedure to the client through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on the consent. The interpreter and client now have a lengthy discussion in the foreign language. The nurse should take which action at this time?
- A. Ask the interpreter to explain the discussion
- B. Confirm the client's consent with the interpreter, using gestures
- C. Have the interpreter witness the signature
- D. Indicate that the interpreter was used when witnessing the client's signature
Correct Answer: A
Rationale: Asking the interpreter to explain the discussion (A) ensures the nurse understands any concerns or clarifications, verifying informed consent. Gestures (B) are unreliable, the interpreter witnessing (C) is inappropriate, and noting interpreter use (D) is insufficient without understanding the discussion.
The nurse is assisting in planning care for a client experiencing an acute attack of Ménière disease. Which action is a high priority to include in the plan of care?
- A. Initiate fall precautions
- B. Keep the emesis basin at bedside
- C. Provide a quiet environment
- D. Start IV fluids
Correct Answer: C
Rationale: A quiet environment (C) reduces sensory overload, a priority in Ménière disease attacks. Fall precautions (A), emesis basin (B), and IV fluids (D) are supportive but less critical.