Nokea
A male client calls for a nurse because of chest pain. Which statement by the client would require the most immediate action by the nurse?
- A. When I take in a deep breath, it stabs like a knife.'
- B. The pain came on after dinner. That soup seemed very spicy.'
- C. When I turn to the left, it feels like my heart is being squeezed.'
- D. The pain radiates to my jaw and left arm.'
Correct Answer: D
Rationale: Chest pain radiating to the jaw and left arm is a classic symptom of myocardial infarction, requiring immediate action to assess for a life-threatening cardiac event.
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The nurse has been teaching a woman who has iron deficiency anemia. Which menu, if selected, indicates that the woman understands her dietary instructions?
- A. Applesauce, green beans, bread, and butter
- B. Peanut butter and jelly sandwich, carrots, and milk
- C. Broccoli, spinach salad with tomatoes, and orange juice
- D. Macaroni and cheese, pickles, and hot chocolate
Correct Answer: C
Rationale: Broccoli, spinach, and orange juice (vitamin C enhances iron absorption) are iron-rich, ideal for anemia. Other menus lack sufficient iron sources.
A client has been newly diagnosed with hypothyroidism and will take levothyroxine (Synthroid) 50 mcg/day by mouth. As part of the teaching plan, the nurse emphasizes that this medication:
- A. Should be taken in the morning
- B. May decrease the client's energy level
- C. Must be stored in a dark container
- D. Will decrease the client's heart rate
Correct Answer: A
Rationale: Should be taken in the morning. Thyroid supplement should be taken in the morning to minimize the side effect of insomnia.
The nurse is reviewing the medication administration record for a 70-year-old client. Which of the following prescribed medications places the client at increased risk for injury? Select all that apply.
- A. diphenhydramine
- B. amitriptyline
- C. simvastatin
- D. famotidine
- E. diazepam
Correct Answer: A,B,E
Rationale: Diphenhydramine (A), amitriptyline (B), and diazepam (E) cause sedation or confusion, increasing fall risk in the elderly. Simvastatin (C) and famotidine (D) do not significantly increase injury risk.
A client who is 2 days post-operative from an appendectomy requests medication for pain. The client's vital signs are as follows: pulse 96, respirations 30, BP 130/92. The nurse should:
- A. Ask whether the client is anxious.
- B. Give the pain medication.
- C. Check the dressing for bleeding.
- D. Recheck the client's vital signs.
Correct Answer: B
Rationale: Pain medication is appropriate for a post-op client with pain and stable vitals. Anxiety may contribute, but pain should be addressed first. Bleeding checks or rechecking vitals are unnecessary without specific indicators.
Which of the following are violations of the Health Insurance Portability and Accountability Act regarding confidentiality of privileged health information? Select all that apply.
- A. A pregnancy result is given to a husband without the wife's permission
- B. The client overhears, through a privacy curtain, the nurse call report on someone
- C. The nurse calls the client by first and last name in the public waiting room
- D. The nurse tells the transporting tech that the client has breast cancer
- E. Unlicensed assistive personnel tell the discharged client, 'You take care now.'
Correct Answer: A,C,D
Rationale: Sharing pregnancy results without consent (A), calling names publicly (C), and disclosing a diagnosis to non-care staff (D) violate HIPAA. Overhearing through a curtain (B) is unintentional, and a general farewell (E) is not a violation.