Nokea
A client who has had a right below-the-knee amputation refers to himself as 'a freak' and 'old peg-leg.' What initial response by the nurse is most therapeutic?
- A. You are not a freak.'
- B. Lots of people have amputations and live a normal life.'
- C. You feel like a freak.'
- D. You shouldn't say that; you are very attractive.'
Correct Answer: C
Rationale: Reflecting the client's feelings ('You feel like a freak') validates their emotions, promoting therapeutic communication. Denying, normalizing, or reassuring dismisses their distress.
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The nurse is teaching a client with a new diagnosis of osteoarthritis about celecoxib (Celebrex). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice
- B. Report any black, tarry stools
- C. Stop the medication if pain decreases
- D. Avoid regular joint exams
Correct Answer: B
Rationale: Black, tarry stools indicate gastroinTest inal bleeding, a serious celecoxib side effect. Options A, C, and D are incorrect: grapefruit juice is irrelevant, stopping the medication may not be advised, and exams are needed.
The nurse is caring for a client with a history of renal failure.
- A. Which laboratory finding is most concerning for a client with chronic renal failure?
- B. Serum creatinine of 2.5 mg/dL.
- C. Serum potassium of 6.2 mEq/L.
- D. Blood urea nitrogen of 30 mg/dL.
- E. Hemoglobin of 10.5 g/dL.
Correct Answer: B
Rationale: A serum potassium of 6.2 mEq/L indicates hyperkalemia, a life-threatening condition in renal failure due to impaired excretion, risking cardiac arrhythmias. Elevated creatinine, BUN, and low hemoglobin are expected but less urgent.
The nurse is planning care for a client who had surgery for an ileal conduit two days ago. It is MOST important for the nurse to take which of the following actions?
- A. Remove the appliance regularly and clean the skin with antiseptic solution.
- B. Apply a close-fitting drainage bag to the stoma.
- C. Massage the skin around the stoma with an emollient.
- D. Expose the area around the stoma to air twice a day.
Correct Answer: B
Rationale: A close-fitting drainage bag prevents urine leakage, protecting skin integrity post-ileal conduit. Options A, C, and D risk skin irritation or bag adhesion issues.
The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which of the following is the BEST response by the nurse?
- A. 11 months of age.
- B. 14 months of age.
- C. 17 months of age.
- D. 20 months of age.
Correct Answer: D
Rationale: by 24 months may be able to achieve daytime bladder control
The home nurse who is caring for an older person who has chronic obstructive pulmonary disease (COPD) with continuous nasal oxygen is helping the family set up a humidifier in the room. The humidifier cord is not long enough to reach the outlet in the room and must be plugged into an extension cord. The extension cord is wrapped with black tape. When the nurse asks the family members about the tape, they reply that the cord is an old cord, and the electrical tape covers up the frayed part and makes it safe. They say a contractor friend told them how to make it safe. How should the nurse respond?
- A. Refuse to set up the equipment until a new cord is available
- B. Carefully inspect the taped area and set up equipment if it appears intact
- C. Ask the family to let the nurse discuss the safety of the cord with the contractor friend
- D. Set up the equipment and suggest that the family get a new extension cord as soon as possible
Correct Answer: A
Rationale: A frayed cord poses a fire hazard, especially with oxygen use. Refusing to set up until a safe cord is available prioritizes safety.