Nokea
A client with a C3 spinal cord injury has a headache and nausea. The client’s blood pressure is 170/100 mm Hg. How should the nurse respond initially?
- A. Administer PRN analgesic medication
- B. Administer PRN antihypertensive medication
- C. Lower the head of the bed
- D. Palpate the client’s bladder
Correct Answer: D
Rationale: Headache, nausea, and hypertension in a C3 injury suggest autonomic dysreflexia, often triggered by bladder distension. Palpating the bladder identifies and addresses the cause. Medications and bed positioning are secondary.
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The nurse is preparing to instill dialysate for a client who is receiving peritoneal dialysis. It would be a priority for the nurse to
- A. place the client in the semi-Fowler position
- B. record the characteristics of the dialysate output
- C. use sterile technique when spiking and attaching the bag of dialysate
- D. ensure that the drainage collection bag is below the level of the abdomen
Correct Answer: C
Rationale: Sterile technique when spiking and attaching the dialysate bag prevents peritonitis, a life-threatening complication. Semi-Fowler positioning, recording output, and bag placement are important but secondary to infection prevention.
The nurse is reinforcing teaching for a client who is a college athlete and was recently diagnosed with moderate persistent asthma. The nurse should instruct the client to avoid
- A. penicillin antibiotics
- B. talc-containing products
- C. strenuous physical activity
- D. secondhand smoke exposure
Correct Answer: D
Rationale: Secondhand smoke is a known asthma trigger, exacerbating symptoms. Penicillin, talc, and strenuous activity are not primary asthma triggers, though activity may require premedication with bronchodilators.
The nurse in the mental health unit is observing staff members communicating with assigned clients. Which of the following statements by a staff member to a client would require the nurse to intervene?
- A. I do not understand what you mean. Can you give me an example?
- B. I understand that you believe the government is out to get you
- C. If you feel comfortable, could you elaborate on how your child died?
- D. Why did you get so angry when your spouse ignored you?
Correct Answer: D
Rationale: Asking 'why' can seem judgmental and provoke defensiveness, hindering therapeutic communication. Seeking clarification, acknowledging beliefs, and inviting elaboration are appropriate and supportive.
The nurse is assigned to care for a client newly diagnosed with angina. As part of discharge teaching, it is important to remind the client to remove the nitroglycerine patch after 12 hours in order to prevent what condition?
- A. Skin irritation
- B. Drug tolerance
- C. Severe headaches
- D. Postural hypotension
Correct Answer: B
Rationale: Drug tolerance. Removing a nitroglycerine patch for a period of 10-12 hours daily prevents tolerance to the drug, which can occur with continuous patch use.
The nurse is teaching the parent of a 7-year-old client with celiac disease. Which statement by the parent would require follow-up?
- A. My child can consume small amounts of barley
- B. My child is allowed to eat rice, corn, and potatoes
- C. My child needs to be on a gluten-free diet for life
- D. My child should avoid eating processed foods
Correct Answer: A
Rationale: Barley contains gluten, which is harmful in celiac disease, indicating a need for further teaching. Rice, corn, potatoes, lifelong gluten-free diet, and avoiding processed foods are correct.