Nokea
A client with a history of chronic migraines is admitted with complaints of photophobia. The nurse should give priority to:
- A. Providing a dark environment
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering oxygen
Correct Answer: A
Rationale: A dark environment reduces photophobia in migraines, improving comfort and reducing symptom severity.
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During a unit card game, a client with acute mania begins to sing loudly as she starts to undress. The nurse should:
- A. Ignore the client's behavior.
- B. Exchange the cards for a checker board.
- C. Send the other clients to their rooms.
- D. Cover the client and walk her to her room.
Correct Answer: D
Rationale: Covering the client and escorting her to a private area maintains dignity and safety, de-escalating the situation caused by manic behavior.
A client with a history of renal failure is admitted with complaints of shortness of breath. The nurse should expect the client to have:
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: Renal failure impairs acid excretion, leading to metabolic acidosis, which can cause compensatory hyperventilation and shortness of breath.
The priority nursing goal when working with an autistic child is:
- A. To establish trust with the child
- B. To maintain communication with the family
- C. To promote involvement in school activities
- D. To maintain nutritional requirements
Correct Answer: A
Rationale: The priority nursing goal when working with an autistic child is establishing a trusting relationship. Maintaining a relationship with the family is important but having the trust of the child is a priority. To promote involvement in school activities is inappropriate for a child who is autistic. Maintaining nutritional requirements is not the primary problem of the autistic child.
A client with a head injury has an order for dexamethasone (Decadron) 10 mg IV; push every 6 hours. The dose is available Decadron 4 mg/mL. How much will the nurse administer?
- A. mL(s)
Correct Answer: 2.5 mL
Rationale: Dose: 10 mg ÷ 4 mg/mL = 2.5 mL.
A mother called the physician's office to ask if it would help relieve her small daughter's abdominal pain if she gave an enema and placed a heating pad on the abdomen. Her daughter has a fever and has vomited twice. The nurse's response is based on the knowledge that:
- A. The symptoms could easily have been caused by constipation, which an enema would relieve
- B. Heat would help to relax the abdominal muscles and relieve her pain
- C. Both heat and enemas stimulate intestinal motility and could increase the risk of perforation
- D. Complaints of stomach ache are common in young children and are generally best ignored
Correct Answer: C
Rationale: Heat and enemas are contraindicated where severe abdominal pain is suspected because they increase intestinal motility and the risk of perforation, especially with fever and vomiting.