Nokea
A client reports that someone is in the room and trying to kill him. The nurse's best response is:
- A. No one is in your room. Let's get you more medicine.'
- B. I do not see anyone, but you seem to be very frightened.'
- C. No one can hurt you here.'
- D. Just tell the person to go away.'
Correct Answer: B
Rationale: It is important to acknowledge the client's fear. The other responses deny the client's perceptions.
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The nurse is caring for a hospitalized client diagnosed with thyrotoxicosis (thyroid storm). Which action is most appropriate to assign to unlicensed assistive personnel?
- A. Call the family to give an update on new aspects of the client's condition
- B. Lower the temperature in the room to make the environment cooler
- C. Reinforce teaching about signs and symptoms of hyperthyroidism
- D. Take vital signs and place a warming blanket on the client
Correct Answer: B
Rationale: Lowering room temperature (B) is within UAP scope and helps manage hyperthermia. Calling family (A), teaching (C), and applying a warming blanket (D) are inappropriate or require nursing judgment.
The nurse is preparing to administer ear drops to a 5-year-old client. Which of the following actions should the nurse take?
- A. Pull the client's pinna upward and back.
- B. Help the client sit upright with the chin tilted down.
- C. Touch the dropper to the entrance of the ear canal.
- D. Remove the medication from the refrigerator just before use.
Correct Answer: A
Rationale: Pulling the pinna upward and back (A) straightens the ear canal in children over 3. Sitting with chin down (B), touching the canal (C), or cold drops (D) are incorrect.
An adult client in an acute care facility says to the nurse, 'I hope this hospital doesn't have student doctors and nurses. I do not want a student taking care of me.' The nurse's response should be based on which of the following understandings?
- A. When a client signs permission for treatment in a hospital, this includes treatment by medical and nursing students.
- B. The client has the right to know if the hospital is affiliated with a medical school and to refuse care by students.
- C. The client may sign a special form that says he refuses to be cared for by medical or nursing students.
- D. The client should be informed if any caregivers are students, but the client does not have the right to refuse to be cared for by students.
Correct Answer: B
Rationale: Clients have the right to know about student involvement and refuse student care, respecting autonomy. Consent doesn't inherently include students, and special forms or mandatory acceptance are incorrect.
The nurse is passing a nasogastric tube into an adult. When passing the tube through the pharynx, the nurse has the client sip water through a straw. What is the purpose of this action?
- A. To prevent dehydration
- B. To divert the client's attention
- C. To close the epiglottis
- D. To lubricate the tube
Correct Answer: C
Rationale: Sipping water during nasogastric tube insertion triggers swallowing, which closes the epiglottis, preventing the tube from entering the trachea and directing it toward the esophagus.
While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?
- A. Strange bed and surroundings
- B. Separation from parents
- C. Presence of other toddlers
- D. Unfamiliar toys and games
Correct Answer: B
Rationale: Separation from parents. Separation anxiety is the greatest stress for a toddler during hospitalization.