Nokea
A client with acute stress disorder is telling the nurse about the tornado that leveled his house and killed his wife and baby while he was out of town on business. He states, 'If only I'd been at home, I could have saved them.' Which of the following responses would be most appropriate?
- A. Don't blame yourself; you'll only feel worse.'
- B. It's not your fault; so stop feeling so guilty.'
- C. You might not have been at home.'
- D. You couldn't have prevented the tornado; it just happened.'
Correct Answer: D
Rationale: Acknowledging the uncontrollable nature of the tornado helps the client process guilt rationally, supporting coping with acute stress disorder.
You may also like to solve these questions
When caring for a client with myasthenia gravis who is receiving anticholinesterase drug therapy, the nurse must be able to distinguish cholinergic crisis from myasthenic crisis. Which of the following symptoms is not present in cholinergic crisis?
- A. Improved muscle strength after I.V. administration of edrophonium chloride (Tensilon).
- B. Increased weakness.
- C. Diaphoresis.
- D. Increased salivation.
Correct Answer: A
Rationale: Improved muscle strength after edrophonium indicates myasthenic crisis, not cholinergic crisis, which involves excessive anticholinesterase effects.
A client with a history of breast cancer is prescribed anastrozole (Arimidex). The nurse should monitor the client for which of the following adverse effects?
- A. Bone loss.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Anastrozole, an aromatase inhibitor, can cause bone loss, increasing osteoporosis risk.
A client with the diagnosis of leukemia is receiving chemotherapy. When the registered nurse (RN) notes that the white blood cell (WBC) count is 4000 mm^3 (4 x 10^9/L), the new nurse caring for the client is informed about the results. Which intervention identified by the new nurse indicates a need for further teaching?
- A. Restricting visitors with colds or respiratory infections
- B. Removing all live plants, flowers, and stuffed animals in the client's room
- C. Placing the client on a low-bacteria diet that excludes raw foods and vegetables
- D. Padding the side rails and removing all hazardous and sharp objects from the room
Correct Answer: D
Rationale: Padding the side rails and removing all hazardous and sharp objects from the environment would be instituted if the client is at risk for bleeding. This client is at risk for infection. When the WBC count is less than 5000 mm^3 (5 x 10^9/L), visitors should be screened for the presence of infection, and any visitors or staff with colds or respiratory infections should not be allowed in the client's room. All live plants, flowers, and stuffed animals are removed from the client's room. The client is placed on a low-bacteria diet that excludes raw fruits and vegetables.
The nurse is caring for a client who has just undergone a parathyroidectomy. Which of the following complications should the nurse monitor for in the immediate postoperative period?
- A. Hypocalcemia.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight loss.
Correct Answer: A
Rationale: Hypocalcemia is a potential complication post-parathyroidectomy due to reduced parathyroid hormone production.
After teaching the parents of a toddler about appropriate snack foods for their child, the nurse judges that the instructions about not giving the child raisins for snacks are effective when the father states should be following?
- A. Raisins are low in nutritional value
- B. Raisins are easy to choke on
- C. Raisins can increase tooth decay
- D. Raisins are hard to digest entirely
Correct Answer: B
Rationale: Raisins are a choking hazard for toddlers due to their size and texture, making this the correct reason to avoid them. Nutritional value, tooth decay, and digestion are less relevant concerns.