Nokea
A client states, 'My life has no meaning right now.' What is the nurse's best response?
- A. Have you been thinking about harming yourself?
- B. How long have you been feeling this way?
- C. Tell me what is going on with you right now.
- D. Do you really think your life has no purpose?
Correct Answer: A
Rationale: The correct answer is A. By asking the client if they have been thinking about harming themselves, the nurse is directly addressing the potential risk of suicide, which is crucial when a client expresses feelings of hopelessness. This question helps assess the client's safety and determine the need for immediate intervention. Choices B, C, and D are not as direct in addressing the potential risk of self-harm and may not provide the necessary urgency in ensuring the client's safety. Asking about self-harm is critical in assessing the severity of the client's distress and ensuring appropriate interventions are implemented promptly.
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A clinic nurse is assessing a client who has measles. Which of the following findings should the nurse expect?
- A. Koplik spots inside the mouth
- B. Persistent low-grade temperature
- C. Muscle aches and tenderness
- D. Rash confined to the trunk of the body
Correct Answer: A
Rationale: The correct answer is A: Koplik spots inside the mouth. These are small, white spots surrounded by a red ring that appear on the buccal mucosa. This finding is characteristic of measles and typically precedes the onset of the rash. Koplik spots are highly specific to measles and can aid in early diagnosis. Persistent low-grade temperature (B) and muscle aches and tenderness (C) are common symptoms of many viral illnesses, including measles, but they are not specific to measles. The rash associated with measles typically starts on the face and head before spreading to the trunk and extremities, so a rash confined to the trunk (D) would not be expected in measles.
A nurse in a mobile health clinic is caring for a client who requires a tetanus immunization and is accompanied by his daughter. The client does not speak the same language as the nurse. Which of the following actions should the nurse take?
- A. Have the client's daughter communicate information about the procedure
- B. Arrange for a member of the client's community to interpret the teaching
- C. Identify the client's spoken dialect prior to contacting an interpreter
- D. Use professional terminology when providing education prior to the procedure
Correct Answer: C
Rationale: The correct answer is C: Identify the client's spoken dialect prior to contacting an interpreter. This is the most appropriate action because it ensures effective communication by matching the client with an interpreter who speaks the same dialect. This step shows cultural sensitivity and respects the client's language preference, promoting trust and understanding.
Other choices are incorrect:
A: Having the client's daughter communicate may not guarantee accurate information exchange due to potential language barriers.
B: Arranging for a community member to interpret may not ensure confidentiality or accuracy in communication.
D: Using professional terminology without ensuring understanding may lead to confusion and hinder effective communication.
A nurse is assessing a client with hyperemesis gravidarum. Which of the following findings should the nurse expect?
- A. Oliguria
- B. Diplopia
- C. Hypoglycemia
- D. Dizziness
Correct Answer: A
Rationale: The correct answer is A: Oliguria. Hyperemesis gravidarum is severe nausea and vomiting during pregnancy, leading to dehydration and electrolyte imbalances. Oliguria, decreased urine output, is expected due to dehydration. Diplopia (B) and dizziness (D) are not specific to hyperemesis gravidarum. Hypoglycemia (C) may occur due to poor oral intake but is not a defining feature.
A nurse is providing teaching to a 50-year-old female client. Which of the following statements should the nurse include in the teaching?
- A. You should have a complete eye examination every 2 years until the age of 64
- B. You should have your hearing screened every 5 years
- C. You should have your stool tested for blood every other year until the age of 74
- D. You should have your fasting blood glucose level checked every 6 years
Correct Answer: A
Rationale: Correct Answer: A - You should have a complete eye examination every 2 years until the age of 64.
Rationale: Regular eye exams help detect common eye conditions such as glaucoma and cataracts early, especially as people age. The American Academy of Ophthalmology recommends eye exams every 2 years for adults aged 40-64. This statement is important for the client's eye health maintenance.
Summary of other choices:
B: Incorrect - Hearing screenings are typically recommended annually for adults over 50, not every 5 years.
C: Incorrect - Stool tests for blood are usually done every year, not every other year until the age of 74, to screen for colorectal cancer.
D: Incorrect - Fasting blood glucose levels should be checked more frequently, at least every 3 years, for early detection of diabetes.
A nurse is caring for a client who is homeless. Which of the following actions should the nurse take first?
- A. Determine the client's understanding of her living situation
- B. Assist the client to develop goals for obtaining shelter
- C. Discuss the risks of being homeless with the client
- D. Develop client teaching using a variety of strategies
Correct Answer: A
Rationale: The correct answer is A: Determine the client's understanding of her living situation. This is the first step because it allows the nurse to assess the client's current situation and needs. Understanding the client's perspective is crucial for providing effective care and support. Assisting the client in developing goals (B) or discussing risks (C) should come after understanding the client's current situation. Developing client teaching (D) is important but should be based on the client's understanding and needs, which is why it comes after assessing their understanding.