Nokea
A female client reports to the nurse that her sleep was interrupted by 'thoughts of anger towards my husband.' What type of thoughts is the client having?
- A. Obsessive.
- B. Phobic.
- C. Delusional.
- D. Paranoid.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Which annual screening should the nurse include when planning eye health programs at a preschool?
- A. visual acuity
- B. red light reflex
- C. conjunctivitis
- D. glaucoma
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is assessing a client with pneumonia who is receiving oxygen therapy. Which finding indicates that the therapy is effective?
- A. The client's respiratory rate is 20 breaths per minute.
- B. The client's arterial blood gases show a pH of 7.35.
- C. The client's oxygen saturation is 92%.
- D. The client's breath sounds are clear.
Correct Answer: A
Rationale: A respiratory rate of 20 breaths per minute indicates effective oxygen therapy. In pneumonia, the respiratory rate typically increases due to the body's effort to improve oxygenation. Option B (pH of 7.35) is related to acid-base balance, not specifically indicating oxygen therapy effectiveness. Option C (oxygen saturation of 92%) is below the normal range (95-100%), suggesting the need for oxygen therapy. Option D (clear breath sounds) is a positive finding but not a direct indicator of oxygen therapy effectiveness.
An older female client tells the home health nurse that she has no money, and since she does not deserve to eat, she has not asked anyone to bring her food. What information is most important for a nurse to obtain?
- A. client's thoughts about wanting to hurt herself
- B. medication history for antipsychotic agents
- C. availability of family members to provide meals
- D. community resources to provide financial aid
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 9-year-old is hospitalized for neutropenia and is placed in reverse isolation. The child asks the nurse, 'Why do you have to wear a gown and mask when you are in my room?' How should the nurse respond?
- A. To protect myself from your germs.
- B. To protect you because you can get an infection very easily.
- C. Until your white blood cell count increases.
- D. To keep others from getting your infection.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client with a history of asthma is admitted with shortness of breath. Which finding requires immediate intervention?
- A. Increased respiratory rate.
- B. Absence of breath sounds.
- C. Expiratory wheezes.
- D. Productive cough with green sputum.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.