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A client with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. The most therapeutic response by the nurse to his refusal is
- A. You need to take your medicine, this is how you get well.
- B. If you refuse your medicine, we'll just have to give you a shot.
- C. What is it about the medicine that you don't like?
- D. I can see that you are uncomfortable right now, I'll wait until tomorrow.
Correct Answer: C
Rationale: What is it about the medicine that you don't like? This fosters trust and open communication, encouraging the client to express concerns.
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The nurse is caring for a client who is receiving IV gentamicin for a gram-negative infection. Which of the following findings would be of GREATest concern to the nurse?
- A. Creatinine 2.0 mg/dL.
- B. Heart rate of 80 bpm.
- C. Blood pressure of 120/80 mmHg.
- D. Temperature of 99.5°F (37.5°C).
Correct Answer: A
Rationale: A creatinine of 2.0 mg/dL indicates renal impairment, a serious complication of gentamicin due to nephrotoxicity, requiring immediate evaluation. Options B, C, and D are normal or less concerning: heart rate 80 bpm, blood pressure 120/80 mmHg, and temperature 99.5°F are stable.
The nurse is caring for a client with a history of hemophilia.
- A. Which intervention is most important for a client with hemophilia experiencing joint pain?
- B. Administer factor replacement therapy.
- C. Apply warm compresses to the joint.
- D. Encourage active range-of-motion exercises.
- E. Administer oral analgesics.
Correct Answer: A
Rationale: Factor replacement therapy stops bleeding in hemophilia, relieving joint pain from hemarthrosis. Cold compresses are used, exercise worsens bleeding, and analgesics are supportive.
A 3 year-old child is brought to the clinic by his grandmother to be seen for 'scratching his bottom and wetting the bed at night.' Based on these complaints, the nurse would initially assess for which problem?
- A. allergies
- B. scabies
- C. regression
- D. pinworms
Correct Answer: D
Rationale: Pinworms are a common cause of anal itching and can contribute to bed-wetting in children due to discomfort. The nurse should assess for signs of pinworm infection, such as observing the anal area for worms or performing a tape test.
The nurse is caring for a client with a pressure ulcer.
- A. Which intervention is most effective for promoting healing of a stage III pressure ulcer?
- B. Apply a hydrocolloid dressing.
- C. Cleanse the wound with hydrogen peroxide.
- D. Reposition the client every 4 hours.
- E. Administer oral antibiotics.
Correct Answer: A
Rationale: A hydrocolloid dressing maintains a moist environment, promoting healing in a stage III pressure ulcer. Hydrogen peroxide is cytotoxic, repositioning every 2 hours is standard, and antibiotics are only used for infection.
The nurse is caring for a client who is receiving intravenous fluid therapy. Which observation needs to be reported to the charge nurse?
- A. The client says the IV fluid feels cool when it goes in.
- B. The infusion site is covered with clear tape.
- C. The client is ambulating while the IV infusion is running.
- D. The area around the infusion site is cool and blanched.
Correct Answer: D
Rationale: A cool, blanched infusion site suggests infiltration or extravasation, requiring immediate reporting to prevent tissue damage. Cool fluid sensation, tape, or ambulation are normal.