Nokea
A client presents to the psychiatric unit crying hysterically. She is diagnosed with severe anxiety disorder. The first nursing action is to:
- A. Demand that she relax
- B. Ask what is the problem
- C. Stand or sit next to her
- D. Give her something to do
Correct Answer: C
Rationale: Standing or sitting next to the client conveys caring and provides a sense of security, reducing anxiety.
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A client with a history of phenylketonuria is seen at the local family planning clinic. After completing the client's intake history, the nurse provides literature for a healthy pregnancy. Which statement indicates that the client needs further teaching?
- A. I can help control my weight by switching from sugar to Nutrasweet.
- B. I need to resume my old diet before becoming pregnant.
- C. I need to eliminate most sources of phenylalanine from my diet.
- D. Fresh fruits and raw vegetables will make excellent between-meal snacks.
Correct Answer: A
Rationale: Nutrasweet (aspartame) contains phenylalanine, which is harmful in phenylketonuria, so this statement indicates a need for further teaching.
The client is admitted with a diagnosis of preterm labor. Which intervention is most appropriate?
- A. Administer betamethasone
- B. Monitor fetal heart tones
- C. Administer tocolytics
- D. All of the above
Correct Answer: D
Rationale: In preterm labor betamethasone enhances fetal lung maturity tocolytics (e.g. nifedipine) halt contractions and fetal heart tone monitoring assesses fetal well-being. All interventions are appropriate.
The nurse is teaching a client with a new colostomy about dietary management. Which food should the client avoid to reduce odor?
- A. Broccoli
- B. Rice
- C. Chicken
- D. Yogurt
Correct Answer: A
Rationale: Broccoli, a cruciferous vegetable, increases colostomy odor due to sulfur compounds. Rice (B), chicken (C), and yogurt (D) are odor-neutral and appropriate.
A client hospitalized with cirrhosis has developed abdominal ascites. The nurse should provide the client with snacks that provide additional:
- A. Sodium
- B. Potassium
- C. Protein
- D. Fat
Correct Answer: C
Rationale: Ascites in cirrhosis is linked to hypoalbuminemia; increasing protein intake helps restore albumin levels, reducing fluid accumulation.
What is the appropriate nursing action for a child with increased intracranial pressure?
- A. Head of bed elevated 45 degrees with child's head maintained in a neutral position
- B. Child lying flat
- C. Head turned to side
- D. Frequent visitation for stimulation
Correct Answer: A
Rationale: Elevating the head of the bed to 45 degrees with a neutral head position promotes venous drainage, reducing intracranial pressure.