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A client with a history of systemic lupus erythematosus (SLE) reports joint pain and fatigue. Which intervention should the nurse prioritize?
- A. Administer analgesics as ordered
- B. Encourage high-impact exercise
- C. Apply cold packs to joints
- D. Restrict fluid intake
Correct Answer: A
Rationale: Administering analgesics addresses joint pain, a common SLE symptom, improving comfort and quality of life.
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The nurse is obtaining a nursing history of a client suspected of having hepatitis C. The nurse should ask the client if he has:
- A. Drunk contaminated water.
- B. Traveled to India.
- C. Had a tattoo.
- D. Eaten shellfish.
Correct Answer: C
Rationale: Hepatitis C is commonly transmitted through blood exposure, such as via tattoos with unsterile equipment. The other options are more associated with hepatitis A.
The nurse is caring for a client at risk for suicide. Which client behavior best indicates that the client may be contemplating suicide?
- A. Sharing that she or he is finally happy
- B. Sitting and crying for long periods of time
- C. Preferring to spend long periods of time alone
- D. Reporting a variety of sleep pattern disturbances
Correct Answer: A
Rationale: If a client displays a suicidal ideation and is able to share a plan, it should be taken very seriously and suicide precautions should be implemented. Expressing happiness shows a contentment that is often a sign that a suicide plan has been created. The remaining options are indicative of depression but are not as definitive in regard to suicide.
Which action by the nursing student, caring for a child who sustained a head injury from a fall, indicates a need for further teaching?
- A. Forcing fluids
- B. Performing neurological assessments
- C. Keeping the child in a sitting-up position
- D. Keeping the child awake as much as possible
Correct Answer: A
Rationale: A child with a head injury is at risk for increased intracranial pressure (ICP). Forcing fluids may cause fluid overload and increased ICP. Additionally, the nurse should not 'force' the client to do something. Neurological assessments must be performed to monitor for increased ICP. Sitting up will decrease fluid retention in cerebral tissue and promote drainage. Keeping the child awake will assist in accurate evaluation of any cerebral edema that is present and will detect early coma.
A primary health care provider has written a prescription for a client diagnosed with diabetic gastroparesis to receive metoclopramide four times a day. The nurse schedules this medication to be given at which times?
- A. With each meal and at bedtime
- B. Thirty minutes before meals and at bedtime
- C. One hour after each meal and at bedtime
- D. Every 6 hours spaced evenly around the clock
Correct Answer: B
Rationale: Metoclopramide stimulates the motility of the upper gastrointestinal tract and is used to treat gastroparesis (nausea, vomiting, and persistent fullness after meals). The client should be taught to take this medication 30 minutes before meals and at bedtime. The before-meals administration allows the medication time to begin working before the client consumes food that requires digestion. The other options suggest information that is incorrect.
A client with a history of rheumatoid arthritis is prescribed hydroxychloroquine (Plaquenil). The nurse should instruct the client to:
- A. Have regular eye exams.
- B. Take the medication on an empty stomach.
- C. Avoid calcium-rich foods.
- D. Stop the medication if joint pain resolves.
Correct Answer: A
Rationale: Hydroxychloroquine can cause retinal toxicity, requiring regular eye exams.