Nokea
A client with benign prostatic hyperplasia (BPH) is preparing for discharge following a transurethral needle ablation (TUNA). Which information should the nurse include in the discharge instructions?
- A. Use an incentive spirometer.
- B. Monitor the urinary stream for the decrease in output.
- C. Report when hematuria becomes pink-tinged.
- D. Restrict physical activities.
Correct Answer: C
Rationale: Reporting pink-tinged hematuria is critical to monitor for complications post-TUNA. Spirometry, urinary stream monitoring, and activity restriction are not specific to TUNA discharge.
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When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, 'What took you so long to get in here!' Which action should the nurse implement?
- A. Request backup from the staff.
- B. Stand in the doorway.
- C. Provide for personal space.
- D. Encourage the client to sit down.
Correct Answer: C
Rationale: Providing personal space reduces the perception of threat, helping de-escalate agitation safely.
A nurse who is co-leading group therapy recognizes that a client is beginning to experience severe levels of anxiety. Which intervention is best for the nurse to implement?
- A. Assist the client with relaxation techniques in the group.
- B. Escort the client from the group to reduce stimuli.
- C. Provide education about ways to cope with anxiety.
- D. Ask the client to describe and identify the source of the feelings.
Correct Answer: A
Rationale: Assisting with relaxation techniques in the group provides immediate anxiety relief and support, suitable for acute anxiety.
The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?
- A. Cancer screening results, anger, gastritis, daily alcohol intake.
- B. Consumption, liver enzyme, gastrointestinal complaints, and bleeding.
- C. Efforts to cut down, annoyance with questions, guilt, and drinking as an 'Eye-opener.'
- D. Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.
Correct Answer: C
Rationale: The CAGE questionnaire assesses alcohol dependency through efforts to cut down, annoyance, guilt, and eye-opener drinking, which should be explored in-depth.
A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?
- A. Ecchymotic blood accumulations.
- B. Evidence of patches of lost hair.
- C. Episodic complaints of pruritus.
- D. Erythema of the localized lesions.
Correct Answer: A
Rationale: Ecchymotic blood accumulations (bruises) suggest trauma or physical manipulation, indicating non-disease-related hair loss. Patches of hair loss, pruritus, or erythema could be associated with medical conditions like alopecia or inflammation.
History and Physical
Nurse's Notes
Orders
The client is in the hospital after her house collapsed during a hurricane. She has been in the intensive care unit for 2 weeks and moved today to the surgical floor to continue monitoring her respiratory function and to complete intravenous antibiotic administration.
For each client statement, click to highlight the statement(s) below that require follow-up teaching by the nurse.
- A. This diagnosis means that I am crazy.'
- B. I can learn to manage my thoughts better through therapy.'
- C. I can use holistic approaches like meditation to help my symptoms.'
- D. Many people have the same response to a stressful situation as I am having right'
- E. I am at high risk for post-traumatic-stress disorder because I have acute stress disorder'
- F. I will probably need to be on medication for the rest of my life.'
Correct Answer: A,C,D,F
Rationale: Statements about being 'crazy,' typical stress responses, holistic approaches, and lifelong medication need clarification to address stigma, variability in trauma responses, and treatment plans.