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A client with a 10-year history of major depressive disorder has relapsed and is now hospitalized. The client is currently on phenelzine and weighs 115 lb (52.2 kg) but weighed 150 lb (68 kg) 3 months before admission. Which foods would be best for this client?
- A. Crackers and cheddar cheese
- B. Hard-boiled egg with tomatoes
- C. Steamed fish and potatoes
- D. Tortilla chips with avocado dip
Correct Answer: C
Rationale: Phenelzine, an MAOI, requires avoiding tyramine-rich foods like cheese (A) to prevent hypertensive crisis. Fish and potatoes (C) are safe and nutritious. Eggs (B) and avocado (D) are safe but less balanced.
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A nurse is participating in an obstetrical emergency simulation in which the health care provider announces shoulder dystocia. Which of the following interventions should the assisting nurse implement?
- A. Assist maternal pushing efforts by applying fundal pressure during each contraction
- B. Document the time the fetal head was born
- C. Flex the client's legs back against the abdomen and apply downward pressure above the symphysis pubis
- D. Prepare for a forceps-assisted birth
- E. Request additional assistance from other nurses immediately
Correct Answer: C,E
Rationale: Shoulder dystocia requires urgent interventions like the McRoberts maneuver (flexing legs back, C) and suprapubic pressure (C) to dislodge the fetal shoulder. Additional assistance (E) is critical. Fundal pressure (A) can worsen impaction. Documentation (B) is secondary to immediate action. Forceps (D) are not typically used for shoulder dystocia.
A client who has been waiting for several hours in the clinic waiting room suddenly begins to shout, 'I need some attention and I need it now!' How should the nurse respond initially?
- A. Tell the client to be quiet and that she will be seen as soon as possible
- B. Immediately call security and the police
- C. Talk with the woman and determine her immediate needs
- D. Explain to the woman how busy the doctors are and that she will be seen soon
Correct Answer: C
Rationale: Engaging the client to assess her needs de-escalates agitation and addresses concerns. Silencing, calling security, or explaining delays may escalate tension.
An elderly client who experiences nighttime confusion wanders from his room into the room of another client. The nurse can best help decrease the client's confusion by:
- A. Assigning a nursing assistant to sit with him until he falls asleep
- B. Allowing the client to room with another elderly client
- C. Administering a bedtime sedative
- D. Leaving a night light on during the evening and night shifts
Correct Answer: D
Rationale: A night light reduces confusion by improving visibility and orientation. Constant supervision is impractical, room-sharing may worsen confusion, and sedatives increase fall risk.
A client complains of some discomfort after a below the knee amputation. Which action by the nurse is most appropriate initially?
- A. Conduct guided imagery or distraction
- B. Ensure that the stump is elevated the first day post-op
- C. Wrap the stump snugly in an elastic bandage
- D. Administer opioid narcotics as ordered
Correct Answer: B
Rationale: Ensure that the stump is elevated the first day post-op. This priority intervention prevents pressure caused by pooling of blood, thus minimizing the pain. Without this measure, a firm elastic bandage, opioid narcotics, or guided imagery will have little effect. Opioid narcotics are given for severe pain.
The mother of a newborn asks why the nurse is checking the baby's nose. The nurse replies that it is important to check nasal patency because the newborn:
- A. does not have the ability to sneeze.
- B. must breathe through his nose.
- C. is subject to periods of apnea.
- D. has rapid respirations.
Correct Answer: B
Rationale: Newborns are obligate nose breathers, making nasal patency critical to prevent respiratory distress. Sneezing ability, apnea, or rapid respirations are unrelated.