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A client with end-stage cancer is receiving morphine for pain. The family is concerned about addiction. The nurse should explain that:
- A. Addiction is not a concern in terminal illness.
- B. Morphine will be tapered to prevent addiction.
- C. Addiction is common but manageable.
- D. Morphine should be avoided to prevent addiction.
Correct Answer: A
Rationale: In terminal illness, addiction is not a concern, as the priority is pain control to ensure comfort, and this explanation reassures the family.
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A client with disseminated intravascular coagulation develops ventricular microvascular thrombosis. The nurse should assess the client for:
- A. Hemoptysis.
- B. Focal ischemia.
- C. Petechiae.
- D. Hematuria.
Correct Answer: B
Rationale: Microvascular thrombosis in DIC can cause focal ischemia by obstructing small vessels, leading to tissue damage in organs like the kidneys or brain. Hemoptysis, petechiae, and hematuria are related to bleeding, not thrombosis.
A male client with a head injury regains consciousness and the normal loss. Which of the following nursing statements is most appropriate as the client awakens?
- A. I'll get your family.
- B. Can you tell me your name and where you live?
- C. I'll bet you're a little confused right now.
- D. You are in the hospital. You were in an accident and unconscious.
Correct Answer: D
Rationale: Providing clear, concise orientation information is most appropriate for a client regaining consciousness to reduce confusion and anxiety. Calling family, asking for personal details, or assuming confusion may overwhelm or distress the client.
A client has been in the position shown in the figure for surgery. The nurse should document that the client has been in which of the following positions?
- A. Reverse Trendelenburg.
- B. Low Fowler's.
- C. High lithotomy.
- D. Prone.
Correct Answer: C
Rationale: The high lithotomy position, used for procedures like vaginal hysterectomy, involves legs elevated in stirrups, as likely depicted in the figure, and should be documented accurately.
A client has a platelet count of 31,000/µL. The nurse should instruct the client to:
- A. Pad sharp surfaces to avoid minor trauma when walking.
- B. Assess for spontaneous petechiae in the extremities.
- C. Keep the room darkened.
- D. Check for blood in the urine.
Correct Answer: A
Rationale: A platelet count of 31,000/µL indicates thrombocytopenia, increasing the risk of bleeding from minor trauma. Padding sharp surfaces helps prevent injuries that could lead to bleeding. Assessing for petechiae or checking urine are monitoring actions, not preventive instructions, and darkening the room is unrelated.
Which of the following family members exposed to tuberculosis would be at highest risk for contracting the disease?
- A. 45-year-old mother.
- B. 17-year-old daughter.
- C. 8-year-old son.
- D. 76-year-old grandmother.
Correct Answer: D
Rationale: The elderly (76-year-old grandmother) are at highest risk due to weakened immune systems, increasing susceptibility to tuberculosis infection. Children and younger adults are less vulnerable unless immunocompromised.