Nokea
A nurse is caring for a client who has an electrical burn. With the client's permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?
- A. He is doing well, although he might be in the hospital for some time.
- B. He has an electrical burn. He is stable, and we will update you with any changes.
- C. He has an electrical burn, which caused coagulation of some tissues.
- D. He does not appear to have much damage and should be fine soon.
Correct Answer: B
Rationale: Providing factual and clear information about the client's condition maintains trust and transparency with the family.
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A nurse is caring for a client who is scheduled to have a colonoscopy. The client states, 'I am so nervous about what the doctor might find during the test.' The nurse asks the client, 'Are you feeling anxious about the results of your colonoscopy?' The nurse's response is an example of which of the following communication techniques?
- A. Clarification
- B. Self-disclosure
- C. Sharing observations
- D. Providing information
Correct Answer: A
Rationale: Clarification helps the nurse ensure understanding of the client's concerns.
A nurse is reinforcing discharge teaching with a client who has a new diagnosis of a latex allergy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply an elastic bandage to a cut.
- B. When cleaning, I like to use dishwashing gloves.
- C. On my son's birthday I plan to buy balloons.
- D. I will use ink pens for writing.
Correct Answer: D
Rationale: The correct answer is D: "I will use ink pens for writing." This statement indicates an understanding of the teaching because ink pens do not contain latex, thus reducing the risk of exposure for someone with a latex allergy. Elastic bandages (choice A) typically contain latex, dishwashing gloves (choice B) may contain latex, and balloons (choice C) are commonly made of latex, all of which could trigger an allergic reaction. Therefore, using ink pens for writing is the safest choice to avoid latex exposure.
A nurse is caring for a school-age child who has metastatic osteosarcoma. While the parents are away, the child is crying and asks the nurse if she is going to die. Which of the following is an appropriate response by the nurse?
- A. Let's talk about what activities you are going to participate in tomorrow.
- B. This is something you should discuss with your parents when they return.
- C. Let's talk about it. Tell me more about what you are thinking.
- D. You need to focus on getting better instead of what may or may not happen.
Correct Answer: C
Rationale: Encouraging the child to express feelings allows the nurse to provide emotional support.
A nurse is collecting data about a client's pulmonary system. While auscultating the client's lungs, the nurse hears continuous gurgling, low-pitched sounds over the trachea and bronchi. Which of the following terms should the nurse use to document this finding?
- A. Rhonchi
- B. Crackles
- C. Wheezing
- D. Friction rub
Correct Answer: A
Rationale: The correct answer is A: Rhonchi. Rhonchi are continuous, low-pitched gurgling sounds heard over the trachea and bronchi. This finding indicates the presence of secretions or mucus in the larger airways. Crackles (B) are discontinuous, popping sounds heard during inspiration and indicate fluid in the alveoli. Wheezing (C) is a high-pitched whistling sound that occurs when air flows through narrowed airways. Friction rub (D) is a grating or rubbing sound heard during inspiration and expiration, caused by inflammation of the pleural surfaces. The other choices are not consistent with the described findings.
A nurse is collecting data from a client who sustained blood loss. Which of the following findings should the nurse identify as a manifestation of hypovolemia?
- A. Decreased heart rate
- B. Dyspnea
- C. Increased blood pressure
- D. Thready pulse
Correct Answer: D
Rationale: The correct answer is D: Thready pulse. Hypovolemia, or low blood volume, leads to decreased blood flow, resulting in a thready pulse due to decreased stroke volume. A: Decreased heart rate is not typically associated with hypovolemia as the body may try to compensate by increasing heart rate. B: Dyspnea may occur in hypovolemic shock, but it is not a specific manifestation of hypovolemia. C: Increased blood pressure is not a typical finding in hypovolemia, as the blood pressure tends to drop due to decreased fluid volume. Thus, D is the correct choice as it directly correlates with the pathophysiology of hypovolemia.