Nokea
A nurse discusses changes due to aging with a group at the senior citizen center. The nurse knows that which of the following changes in the pattern of urinary elimination normally occur with aging?
- A. Decreased frequency.
- B. Incontinence.
- C. Sphincter reflexes decrease.
- D. Formation of bladder stones.
Correct Answer: B
Rationale: ureters, bladder, and urethra lose muscle tone results in stress and urge incontinence
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The nurse has just received report from the previous shift. Which of the following clients should the nurse see FIRST?
- A. A client with chronic renal failure complaining of swollen fingers and ankle edema.
- B. A client one-day postoperative after abdominal surgery who has dried blood on the abdominal dressing.
- C. A client with type I diabetes mellitus who states, 'I have this quivering feeling in my abdomen.'
- D. A client on high doses of antibiotics for a resistant infection who complains of diarrhea.
Correct Answer: C
Rationale: indicates hypoglycemia; symptoms include tachycardia, cold and clammy skin, weakness and pallor; check blood sugar, offer milk
A middle-aged female client begins outpatient therapy sessions with a psychiatric clinical nurse specialist for management of a phobic disorder. Which of the following nursing interventions should be an initial approach in symptom reduction?
- A. Referral for psychopharmacologic intervention.
- B. Group psychotherapy.
- C. Systematic desensitization.
- D. Biofeedback.
Correct Answer: C
Rationale: phobic disorders are learned responses; learned responses can be unlearned through certain techniques, such as behavioral modification; systematic desensitization is a form of behavior modification; is a strategy used in conjunction with deep muscle relaxation to decrease the extreme response to anxiety-producing situations as they are gradually exposed; then exposure is increased; goal is to eradicate the phobic response by replacing it with the relaxation response
The nurse is caring for a 22-year-old woman who is completing the first stage of labor. The woman's husband is at her side and has been coaching her according to exercises they learned at natural childbirth classes. Suddenly the woman begins to shake and screams, 'I can't stand this anymore!' The nurse should encourage the husband to
- A. instruct his wife to use shallow respirations during the contractions.
- B. offer his wife ice chips or sips of water to distract her from the pain.
- C. stroke his wife's abdomen between contractions.
- D. review with his wife the breathing pattern needed at each stage of labor.
Correct Answer: A
Rationale: entering transition phase of first stage of labor, slow shallow breaths needed (pant breathing)
A 36-year-old client tested positive for the tuberculosis antibody and was placed on isoniazid (INH) four weeks ago. The nurse would be MOST concerned if which of the following was observed?
- A. Fatigue and dark urine.
- B. Malaise and glucosuria.
- C. Proteinuria and lethargy.
- D. Diluted urine and epigastric distress.
Correct Answer: A
Rationale: initial indications of hepatic dysfunction
The nurse is receiving a bedside report from another nurse. The nurse giving the report begins to talk about another client. Which action by the nurse receiving the report is MOST appropriate?
- A. Ask the nurse to report on this client only.
- B. Ask the nurse to lower his/her voice.
- C. Ask the nurse to move to another part of the room.
- D. Ask the nurse to clarify which client s/he is reporting on.
Correct Answer: A
Rationale: client confidentiality is being violated, nurse should intervene to protect client