Nokea
A nurse has been assigned to provide care to a client with suicidal ideation who is receiving treatment in an outpatient setting. The nurse develops a care plan and reviews it with the nurse preceptor before meeting with the client. Which proposed nursing action in the care plan requires intervention by the nurse preceptor?
- A. Assist the client in identifying the warning signs of a crisis
- B. Have the client write a list of people to contact for help and distraction
- C. Help the client develop ways of coping with suicidal thoughts
- D. Persuade the client to sign a contract promising not to attempt suicide
Correct Answer: D
Rationale: No-suicide contracts are not evidence-based and may create pressure rather than support coping strategies.
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The nurse makes a home visit to a client with Alzheimer disease. While reviewing the client's home care needs, the client's spouse states, 'It's hard to see my spouse worsen each day. I'm not sure I can keep doing this alone anymore.' Which response by the nurse is best?
- A. Perhaps finding a caregiver to care for your spouse at night might be helpful.
- B. Tell me about the care you provide in a typical day and its challenges.
- C. Try not to worry. It's normal to feel overwhelmed when you are stressed.
- D. You seem worried that you won't be able to provide the care that your spouse needs.
Correct Answer: B
Rationale: Exploring the spouse's daily challenges encourages open communication and helps identify specific support needs.
The nurse finds a person unresponsive on the floor. What is the initial nursing action?
- A. Start chest compressions
- B. Assess respirations and pulse
- C. Place on a hard surface
- D. Start mouth-to-mouth breathing
Correct Answer: B
Rationale: Assessing respirations and pulse determines if CPR is needed, per ACLS guidelines. Compressions, positioning, or breathing are premature without confirming unresponsiveness and absence of pulse/breathing.
Following a stroke, an elderly client develops ptosis. When assessing the client, the nurse will note:
- A. Drooping of the eyelid on the affected side
- B. Inverted eyelid margins
- C. Eversion of eyelid margins
- D. Granulomatous inflammation of the eyelids
Correct Answer: A
Rationale: Ptosis or drooping of the eyelid can occur as the result of a stroke or Bell's palsy. Answer B refers to entropion, and answer C refers to ectropion, so they are incorrect. Answer D refers to chalazion, so it's incorrect. Answers B, C, and D are incorrect because they do not relate to ptosis.
The pediatric nurse is reinforcing education about medication administration to the parents of a 4-year-old client. Which statements made by the parents demonstrate correct understanding? Select all that apply.
- A. I can mix the medication in a bowl of my child's favorite cereal.
- B. I should give another dose if my child vomits after taking the medication.
- C. I should measure liquid medications using an oral syringe.
- D. I will encourage my child to help me as I prepare the medication.
- E. I will place my child in time-out if the medication is refused.
Correct Answer: C
Rationale: Using an oral syringe ensures accurate dosing. Mixing with food, redosing after vomiting, involving the child in preparation, or punishing refusal are inappropriate.
The nurse is observing continuous cardiac monitoring for assigned clients. Which of the following cardiac rhythms would immediate follow-up?
Correct Answer: C
Rationale: Ventricular fibrillation (VF) is a lethal dyshythmia characterized by disorganized electrical activity in the heart ventricles. Because
of this erratic electrical activity, the heart muscles lose the ability to contract, resulting in loss of blood flow and pulse (ie, cardiac
arrest). Nurses who identify a client with VF should immediately check the pulse, start CPR, and prepare the client for defibrillation