Nokea
A client who has been diagnosed with anorexia nervosa refuses to eat lunch. The most therapeutic response by the nurse to her refusal is:
- A. Okay, missing one meal won't hurt.'
- B. You'll have to eat lunch, or we'll force-feed you.'
- C. It's not appropriate for you to try to manipulate the staff into granting your wishes.'
- D. We will not allow you to starve yourself. You may choose to eat voluntarily or be fed.'
Correct Answer: D
Rationale: Setting limits assures the client that staff has genuine concern for her safety and well-being. Giving her an actual choice will give the client an increased sense of control over her life and avoid an argument or power struggle.
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The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT,the nurse should:
- A. Apply a tourniquet to the client's arm
- B. Administer an anticonvulsant medication
- C. Ask the client if he is allergic to shellfish
- D. Apply a blood pressure cuff to the arm
Correct Answer: D
Rationale: A blood pressure cuff is applied to one limb during ECT to monitor for seizure activity (visible in the uncuffed limb). Tourniquets anticonvulsants and shellfish allergies are not relevant to ECT preparation.
The RN on the oncology unit is preparing to mix and administer amphoteracin B (Fungizone) to a client. Which action is contraindicated for administering this drug IV?
- A. Mix the drug with normal saline solution.
- B. Administer the drug over 4-6 hours.
- C. Hydrate with IV fluids two hours before the infusion is scheduled to begin.
- D. Premedicate the client with ordered acetaminophen (Tylenol) and diphenhydramine (Benadryl).
Correct Answer: A
Rationale: Amphotericin B should be mixed with D5W, not normal saline, due to stability issues. Slow infusion (B), hydration (C), and premedication (D) are standard practices.
The nurse is caring for a client with a diagnosis of hyperemesis gravidarum. Which laboratory finding is most likely to be present?
- A. Metabolic alkalosis
- B. Hyponatremia
- C. Hypokalemia
- D. All of the above
Correct Answer: D
Rationale: Hyperemesis gravidarum causes prolonged vomiting leading to metabolic alkalosis (loss of stomach acid) hyponatremia (electrolyte loss) and hypokalemia (potassium loss). All are likely findings in severe cases.
In performing the initial nursing assessment on a client at the prenatal clinic, the nurse will know that which of the following alterations is abnormal during pregnancy?
- A. Striae gravidarum
- B. Chloasma
- C. Dysuria
- D. Colostrum
Correct Answer: C
Rationale: Dysuria is abnormal and may indicate a urinary tract infection, unlike the other options, which are normal pregnancy changes.
The client is prescribed methotrexate for rheumatoid arthritis. Which instruction should the nurse include?
- A. Take the medication with milk to prevent stomach upset.'
- B. Report any signs of infection immediately.'
- C. Avoid exposure to sunlight.'
- D. Take the medication only when joint pain is severe.'
Correct Answer: B
Rationale: Methotrexate causes immunosuppression, increasing infection risk, so reporting signs of infection is critical. Milk does not prevent GI upset, photosensitivity is not a primary concern, and methotrexate is taken regularly, not as needed.