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A client who is withdrawing from alcohol says to the nurse, 'There are snakes on the wall.' Which action should the nurse take initially?
- A. Reassure the client that there are no snakes
- B. Turn the lights on brighter
- C. Tell the client that while he may see snakes, there are really no snakes
- D. Reassure the client that the snakes will not hurt him
Correct Answer: C
Rationale: Acknowledging the hallucination (delirium tremens) as perceived but clarifying reality reduces agitation without confrontation. Reassurance or lighting changes are less effective.
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The greatest threat during the immediate post-burn period results from burn shock. Which of the following statements best describes why burn shock occurs?
- A. Damaged tissues release histamine and other substances that can result in vasodilatation and increased capillary permeability with a loss of fluid from the vascular compartment to the interstitial space.
- B. Large amounts of fluid are lost from the burn site, which results in a decrease in circulating volume.
- C. Large amounts of epinephrine are released, leading to severe vasoconstriction and shock.
- D. Release of epinephrine leads to tachycardia, ineffective cardiac output, and shock.
Correct Answer: A
Rationale: Burn shock occurs due to histamine release causing vasodilation and increased capillary permeability, leading to fluid loss from the vascular to interstitial space.
A woman calls the physician's office stating that her 16-year-old daughter took 20 or 30 sleeping pills. The mother tells the nurse that her daughter is awake and says, 'Leave me alone. I just want to die.' How should the nurse respond?
- A. Ask her why she wants to die.'
- B. Try to convince her that she wants to live.'
- C. Give her a glass of milk to bind the medication.'
- D. Call 911 and get her to the closest emergency room immediately.'
Correct Answer: D
Rationale: A suicide attempt with sleeping pills requires immediate emergency care to prevent overdose complications. Other responses delay critical intervention.
The LPN/LVN is caring for an adult who has pneumonia. The nurse should instruct the nursing assistant to report which information immediately?
- A. Restlessness
- B. Pink-colored skin
- C. Nonproductive cough
- D. Dry mouth
Correct Answer: A
Rationale: Restlessness may indicate hypoxia in pneumonia, a critical symptom requiring immediate reporting to assess oxygenation status.
A client is to begin taking Fosamax. The nurse must emphasize which of these instructions to the client when taking this medication? 'Take Fosamax
- A. on an empty stomach.'
- B. after meals.'
- C. with calcium.'
- D. with milk 2 hours after meals.'
Correct Answer: A
Rationale: Fosamax should be taken first thing in the morning with 6-8 ounces of plain water at least 30 minutes before other medication or food. Food and fluids (other than water) greatly decrease the absorption of Fosamax. The client must be instructed to remain in the upright position for 30 minutes following the dose to facilitate passage into the stomach and minimize irritation of the esophagus.
A client is admitted with suspected fracture of the left hip. The most consistent finding in the client with the hip fracture is:
- A. Pain in the hip and affected leg
- B. Absence of pedal pulses
- C. Disalignment of the leg
- D. Diminished sensation
Correct Answer: C
Rationale: Disalignment of the leg , such as shortening or external rotation, is the most consistent sign of a hip fracture. Pain is common but less specific. Pulses and sensation are typically intact.