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A client with heart failure expresses feelings of burden and thoughts of death to a nurse. How should the nurse respond?
- A. Would you like to talk more about this?
- B. You are lucky to have such a devoted daughter.
- C. It is normal to feel as though you are a burden.
- D. Would you like to meet with the chaplain?
Correct Answer: A
Rationale: The correct answer is A because it demonstrates active listening and empathy, encouraging the client to express their feelings further. This response shows support and openness to discuss sensitive topics, promoting therapeutic communication. Choice B fails to address the client's emotional distress directly. Choice C may invalidate the client's feelings. Choice D may not be appropriate unless the client expresses interest in meeting with the chaplain. Overall, option A is the best response for addressing the client's emotional needs effectively.
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In developing a discharge plan for a patient requiring home-care services, what is important to assess?
- A. Patient’s nursing diagnosis
- B. Availability of needed community services
- C. Patient’s functional abilities
- D. Patient’s family dynamics
Correct Answer: B
Rationale: Ensuring access to necessary community services is vital for successful home care.
16. Which statement accurately describes the common use of feverfew?
- A. Frequently used for insomnia and anxiety
- B. Most commonly used for prevention of migraine headaches
- C. Frequently used to prevent and treat upper respiratory infections
- D. Often used by perimenopausal women to relieve menopausal symptoms
Correct Answer: B
Rationale: Feverfew is most commonly used for the prevention of migraine headaches, making option B the correct answer.
While on a hiking trip, Mr. Jones states that a branch of a tree struck his eye. Part of the branch remains lodged in the eye, and the eyelid is bleeding. Appropriate emergency treatment would include
- A. covering the eye with a protective shield
- B. encouraging Mr. Jones to hold his eye closed tightly
- C. applying a pressure dressing to the eye
- D. removing the foreign body and applying a sterile dressing
Correct Answer: A
Rationale: Covering the eye with a protective shield prevents further injury while awaiting professional medical evaluation and removal of the foreign object.
What priority nursing action should you take?
- A. Notify the physician immediately
- B. Administer supplemental oxygen
- C. Have the student breathe into a paper bag
- D. Obtain an order for an anxiolytic medication
Correct Answer: C
Rationale: Breathing into a paper bag can help rebalance carbon dioxide levels in a patient experiencing hyperventilation.
Following a gastric resection, a 70-year-old male client is admitted to the Post-Anesthesia Care Unit (PACU). The client was extubated prior to leaving the OR suite. Upon arrival at the PACU, the nurse should first:
- A. check the client's airway to feel for the amount of air exchange, noting the rate, depth, and quality of respirations.
- B. obtain pulse and blood pressure readings, noting the rate and quality of the client's pulse.
- C. reassure the client that his surgery is over and that he is in the recovery room.
- D. review the doctor's orders to administer any medications ordered.
Correct Answer: A
Rationale: Adequate air exchange and tissue oxygenation depends upon competent respiratory function. Checking the airway is the nurse's priority action. Obtaining the vital signs is an important action, but is secondary to airway management. Re-orienting a client to time, place, and person and knowing that their surgery is over is important, but is secondary to airway management and taking vital signs. Airway management takes precedence over the physician's orders, unless the orders specifically relate to airway management.