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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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.
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 client with a diagnosis of Schizophrenia has been released from an acute care setting. The client had a prolonged recovery from relapse. One of the parents says to the discharge nurse, 'I do not understand what is going on. The hospital said she was better, but all she does is sit around all day and smoke. We cannot get her to go to the vocational training you arranged.' The nurse recognizes that more teaching is needed about:
- A. the pathophysiology and acting out behaviors of schizophrenia.
- B. support groups that can help the parents release their feelings of frustration.
- C. the prolonged recovery time and depressive effects of medicines to prevent relapse.
- D. motivational techniques that are effective in clients with schizophrenia.
Correct Answer: C
Rationale: The nurse conducting discharge teaching must stress the lengthy recuperation process with emphasis on the sedative qualities of the medication used to prevent relapse. Support groups are useful for caregivers. The emphasis during recuperation is on maintaining nutrition and hygiene.
A nurse is performing a screening on a patient that has been casted recently on the left lower extremity. Which of the following statements should the nurse be most concerned about?
- A. The patient reports, 'I didn't keep my extremity elevated like the doctor asked me to.'
- B. The patient reports, 'I have been having pain in my left calf.'
- C. The patient reports, 'My left leg has really been itching.'
- D. The patient reports, 'The arthritis in my wrists is flaring up, when I put weight on my crutches.'
Correct Answer: B
Rationale: Pain may be indicating neurovascular complication.
Two staff nurses were considered for promotion to head nurse. The promotion is announced via a memo on the unit bulletin board. The nurse who was not promoted tells a friend, 'Oh, well, I really didn't want the job anyway.' This is an example of:
- A. rationalization.
- B. denial.
- C. projection.
- D. compensation.
Correct Answer: A
Rationale: This is called the sour grapes form of rationalization. Rationalization is an unconscious form of self-deception in which excuses are made.