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A multigravid client at 36 weeks' gestation who is visiting the clinic for a routine visit begins to sob and tells the nurse, 'My boyfriend has been beating me up once in a while since I became pregnant'”but I can't bring myself to leave him because I don't have a job and I don't know how I would take care of my other children.' Which of the following actions should be the priority by the nurse at this time?
- A. Contact a social worker for assistance and family counseling.
- B. Help the client make concrete plans for the safety of herself and her children.
- C. Tell the client and how anyone to hit her or her children.
- D. Provide the client with brochures on the statistics about violence against women.
Correct Answer: B
Rationale: Prioritizing safety planning protects the client and her children from further abuse.
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The nurse applies warm compresses to a client's leg. To determine effectiveness of the compresses, the nurse should determine if there is:
- A. Less scaling on the skin.
- B. Decreased bruising.
- C. Improved circulation to the area.
- D. Decreased swelling in the area.
Correct Answer: C
Rationale: Warm compresses promote vasodilation, improving circulation to the area, which aids healing and reduces symptoms.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is prescribed fluticasone (Flovent). The nurse should instruct the client to:
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after using the inhaler.
- C. Shake the inhaler before use.
- D. Take two puffs twice daily.
Correct Answer: B
Rationale: Rinsing the mouth after using fluticasone prevents oral candidiasis, a common side effect of inhaled corticosteroids.
The nurse is teaching a client with a new diagnosis of celiac disease about dietary management. Which of the following foods should the client avoid?
- A. Rice.
- B. Wheat.
- C. Corn.
- D. Potatoes.
Correct Answer: B
Rationale: Wheat contains gluten, which must be avoided in celiac disease.
A nurse is admitting an older female client to the gynecology surgical unit. When the nurse asks the client what medication she is taking at home, the client responds that she is taking a little red pill in the morning and a white capsule at night for her blood pressure. What action by the nurse is focused on safe, effective care of this client?
- A. Consult the pharmacist regarding identification of the medications.
- B. Show pictures to the client from the Physician's Desk Reference to identify the medications.
- C. Consult the previous medical record and notify the physician regarding medications that must be ordered.
- D. Ask a family member to bring the medications from home in the original vials for proper identification and administration times.
Correct Answer: D
Rationale: Having medications brought in original vials ensures accurate identification, promoting safe administration.
A client asks the nurse how long she has to take her medicine for hypothyroidism. The nurse's response is based on the knowledge that:
- A. Lifelong daily medicine is necessary.
- B. The medication is expensive, and the dose can be reduced in a few months.
- C. The medication can be gradually withdrawn in 1 to 2 years.
- D. The medication can be discontinued after the client's thyroid-stimulating hormone level is normal.
Correct Answer: A
Rationale: Hypothyroidism typically requires lifelong thyroid hormone replacement therapy, as the condition is usually permanent due to underlying thyroid dysfunction.