Nokea
A client is being discharged after receiving an implantable cardioverter defibrillator. Which statement by the client indicates that teaching has been effective?
- A. I’m not worried about the device firing now because I know it won’t hurt.
- B. I will let my daughter fix my hair until my health care provider says I can do it.
- C. I will look into public transportation because I won’t be able to drive again.
- D. I will notify my travel agent that I can no longer travel by plane.
Correct Answer: B
Rationale: Avoiding hair-fixing (B) prevents arm movement that could dislodge leads, showing effective teaching. Device firing (A) can be uncomfortable, driving (C) is restricted temporarily, and air travel (D) is generally safe with precautions.
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A young adult is admitted to the psychiatric unit because she has become very withdrawn and has stopped attending college classes. She sits for hours rocking back and forth and appears to be talking to someone at intervals. She does not eat or bathe or relate to others. How should the nurse approach this client upon admission?
- A. Explain the unit routines to her in detail
- B. Ask her if she has any question about the unit or what she is supposed to do
- C. Briefly explain the most essential information and then sit with her
- D. Take her by the hand and orient her to the unit
Correct Answer: C
Rationale: A withdrawn client may be overwhelmed by detailed explanations. Brief information and quiet presence build trust and reduce anxiety.
The nurse observes a client using a walker. Which observation indicates that the client needs more instruction?
- A. The client uses the walker to pull herself out of a chair.
- B. The client moves the walker forward and then takes a step.
- C. The client complains that the walker is not waist high.
- D. The client sometimes does not use the walker.
Correct Answer: A
Rationale: Using the walker to pull up risks tipping, indicating improper use and a need for further instruction on safe walker technique.
A mother noticed a large abdominal mass when helping her 3-year-old child bathe. The child is taken to the physician and admitted to the hospital after an intravenous pyelogram (IVP) confirms the diagnosis of Wilms' tumor. Which nursing action is essential to include in the nursing care plan?
- A. Strain all urine and save for analysis.
- B. Avoid palpating the abdomen.
- C. Prepare the child for permanent dialysis.
- D. Help the family understand the poor prognosis.
Correct Answer: B
Rationale: Avoiding abdominal palpation prevents potential tumor rupture or metastasis in Wilms' tumor, a critical precaution. Urine straining, dialysis, or poor prognosis are inappropriate.
To maintain Bryant's traction, the nurse must make certain that the child's:
- A. Hips are resting on the bed with the legs suspended at a right angle to the bed
- B. Hips are slightly elevated above the bed with the legs suspended at a right angle to the bed
- C. Hips are elevated above the level of the body on a pillow with the legs suspended parallel to the bed
- D. Hips and legs are flat on the bed with the traction positioned at the foot of the bed
Correct Answer: B
Rationale: Bryant's traction requires hips slightly elevated and legs at a right angle to the bed to align the femur properly and reduce pressure on the pelvis.
A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the 'evil eye.' The nurse should communicate to other personnel that the appropriate approach is to
- A. Touch the baby after looking at him
- B. Talk very slowly while speaking to him
- C. Avoid touching the child
- D. Look only at the parents
Correct Answer: A
Rationale: In many cultures, an 'evil eye' is cast when looking at a person without touching him. Thus, the spell is broken by touching while looking or assessing.