Nokea
A nurse gave medications to the wrong client. She stated the client responded to the name called. What is the nurse's appropriate documentation?
- A. Note in medication records the drug given
- B. The client was not hurt, no need for documentation
- C. Note the client's orientation
- D. Completely fill out an incident report
Correct Answer: D
Rationale: The incident report should always be filled out involving medication errors.
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A 60-year-old widower is hospitalized after complaining of difficulty sleeping, extreme apprehension, shortness of breath, and a sense of impending doom. What is the best response by the nurse?
- A. You have nothing to worry about. You are in a safe place. Try to relax.'
- B. Has anything happened recently or in the past that might have triggered these feelings?'
- C. We have given you a medication that helps to decrease feelings of anxiety.'
- D. Take some deep breaths and try to calm down.'
Correct Answer: B
Rationale: Choice 2 provides support, reassurance, and an opportunity to gain insight into the cause of the anxiety. Choice 1 dismisses the client's feelings and offers false reassurance. Choices 3 and 4 do not allow the client to discuss his feelings, which he must do in order to understand and resolve the cause of his anxiety.
A corporate executive works 60-80 hours a week. The client is experiencing some physical signs of stress. The nurse teaches the client biofeedback techniques. This is an example of which of the following health-promotion interventions?
- A. structure
- B. relaxation technique
- C. time management
- D. regular exercise
Correct Answer: B
Rationale: Biofeedback is a relaxation technique that helps manage stress by teaching control over physiological responses, addressing the client's stress-related symptoms.
Which statement about chemotherapy is true?
- A. It is a local treatment affecting only tumor cells.
- B. It is a systemic treatment affecting both tumor and normal cells.
- C. It has not yet been proved an effective treatment for cancer.
- D. It is often the drug of choice because it causes few, if any, side effects.
Correct Answer: B
Rationale: 5-FU is an antineoplastic, antimetabolic drug that inhibits DNA synthesis and interferes with cell replication. It is given intravenously and acts systemically. It affects all rapidly growing cells, both malignant and normal. It is used as adjuvant therapy for treating cancer of the colon, rectum, stomach, breast, and pancreas. This drug has many side effects, including bone marrow depression, anorexia, stomatitis, nausea, and vomiting.
Ten-year-old Jackie is admitted to the hospital with a medical diagnosis of Rheumatic Fever. She relates a history of 'a sore throat about a month ago.' Bed rest with bathroom privileges is prescribed. Which of the following nursing assessments should be given the highest priority when assessing Jackie's condition?
- A. her response to being hospitalized
- B. the presence of a macular rash on her trunk
- C. her cardiac status
- D. the presence of polyarthritis and pain in her joints
Correct Answer: C
Rationale: Monitoring cardiac status is of the highest priority. Permanent cardiac damage can result from rheumatic fever. The second priority is assessing the client's joints for the presence of polyarthritis and accompanying pain.
After group therapy, the female victim of intimate partner violence confides to the nurse that she does not feel in any immediate danger. Which of the following statements about victims of domestic violence is true?
- A. Victims of domestic violence are often the best predictors of their risk of harm.
- B. Victims of domestic violence often overestimate their safety risk.
- C. Victims of domestic violence are typically in a state of denial.
- D. Victims of domestic violence know that keeping peace with their partner is the best method of preventing another attack.
Correct Answer: A
Rationale: Victims of domestic violence are often correct at predicting their risk of harm. However, the nurse should ensure that the client is expressing herself authentically and is not trying to convince the nurse that there is no immediate danger. Further, proper authorities, such as the police, should be alerted to this reportable offense.