Nokea
A nurse is caring for a client who has a new diagnosis of diabetes mellitus and is refusing to learn how to self-administer Insulin. Which of the following responses should the nurse make?
- A. Why don't you want to learn how to give yourself your medication?
- B. I'd like to hear your thoughts about giving yourself this medication.
- C. Have you considered how your decision to refuse medication will affect your family?
- D. You will suffer serious health issues if you don't take your medication.
Correct Answer: B
Rationale: Inviting the client to share thoughts encourages open communication and respects their perspective, facilitating understanding of barriers to learning.
You may also like to solve these questions
A nurse is caring for a client who is receiving oxygen at 2 L/min via nasal cannula. Which of the following actions should the nurse take?
- A. Apply petroleum jelly to the client's nares.
- B. Secure the cannula tubing behind the client's ears.
- C. Change the nasal cannula every 24 hr.
- D. Ensure the oxygen tubing is free of kinks.
Correct Answer: D
Rationale: Kink-free tubing ensures proper oxygen delivery. Petroleum jelly risks aspiration, securing tubing varies, and cannula changes aren't daily.
A nurse is reinforcing teaching with new parents about car seat safety. Which of the following instructions should the nurse include?
- A. Keep the airbag on if the car seat is in the front seat.
- B. Position the car seat at a 90° angle.
- C. Put a small cushion under the newborn's head for support.
- D. Place the shoulder harnesses at the level of the infant's shoulders.
Correct Answer: D
Rationale: Shoulder harnesses at shoulder level ensure a secure fit, enhancing safety. Airbags should be off for front-seat car seats, the angle should be 45°, and cushions can disrupt proper positioning.
A nurse is caring for a client who is receiving IV fluids. Which of the following actions should the nurse take to prevent infection?
- A. Change the IV tubing every 24 hr.
- B. Clean the IV insertion site with alcohol before insertion.
- C. Monitor the IV site for redness or swelling.
- D. Use a new IV catheter for each attempt.
Correct Answer: C
Rationale: Monitoring for redness or swelling detects infection early. Tubing changes are every 72-96 hours, alcohol is standard, and new catheters are used per attempt.
A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse take if a transfusion reaction is suspected?
- A. Increase the infusion rate.
- B. Administer diphenhydramine.
- C. Stop the transfusion.
- D. Elevate the client's legs.
Correct Answer: C
Rationale: Stopping the transfusion prevents further reaction. Increasing the rate worsens it, diphenhydramine is secondary, and leg elevation is unrelated.
A nurse is caring for a client who has schizophrenia and is taking an antipsychotic medication. Which of the following screening tools should the nurse use to identify tardive dyskinesia?
- A. Patient Health questionnaire 9
- B. Mental Status Examination
- C. Brief Psychiatric Rating Scale
- D. Abnormal Involuntary Movement Scale
Correct Answer: D
Rationale: The AIMS is designed to detect tardive dyskinesia, a side effect of antipsychotics. Other tools assess depression, cognition, or general psychiatric symptoms.