Nokea
A nurse is caring for a postoperative client following a total knee replacement. Which of the following medications should the nurse anticipate the provider to prescribe to prevent the formulation of a deep vein thrombosis (DVT)?
- A. Enoxaparin
- B. Alteplase (tPA)
- C. Warfarin
- D. Clopidogrel
Correct Answer: A
Rationale: The correct answer is A: Enoxaparin. Enoxaparin is a low molecular weight heparin that helps prevent deep vein thrombosis (DVT) by inhibiting clot formation. It is commonly prescribed postoperatively for clients undergoing knee replacement surgery due to the increased risk of DVT. Alteplase (tPA) is a thrombolytic agent used to dissolve existing blood clots and not typically used for prevention. Warfarin is an oral anticoagulant that requires monitoring of INR levels and is usually started after initial treatment with heparin. Clopidogrel is an antiplatelet agent and is not typically used for DVT prevention.
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A nurse is caring for a client who has been diagnosed with end-stage liver cancer. The nurse recognizes that which of the following responses is an indication that the client is in the denial phase of the grief process?
- A. I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer!
- B. Even though I am not hurting right now, I don't feel like I have the energy to get out of bed.
- C. The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication.
- D. The doctor has been so good to me. I know he has tried everything he can. It's just my time.
Correct Answer: C
Rationale: The correct answer is C. In this response, the client is demonstrating denial by refusing to accept the doctor's prognosis of having only a few months to live. This indicates an inability to acknowledge the severity of the situation, a common characteristic of the denial phase in the grief process. The client's belief that the doctor is exaggerating shows a defense mechanism to cope with the overwhelming truth. Options A, B, and D do not exemplify denial. Option A shows anger, Option B indicates depression, and Option D reflects acceptance and resignation, which are not characteristics of denial in the grief process.
A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Ritualistic behavior
- B. Short attention span
- C. Spinning a toy repetitively
- D. Consistent limit testing
- E. Delayed language development
Correct Answer: A,B,C,E
Rationale: The correct findings for a child with autism spectrum disorder are A, B, C, and E. A: Ritualistic behavior is common in children with ASD due to their need for predictability and routine. B: Short attention span is often seen in children with ASD, affecting their ability to focus on tasks. C: Spinning a toy repetitively is a stereotypical behavior associated with ASD, serving as a self-soothing mechanism. E: Delayed language development is a hallmark feature of ASD, impacting communication skills. These findings align with the core characteristics of ASD. Choices D and beyond are incorrect as they do not typically align with common manifestations of ASD in children.
A nurse is providing teaching to a client who has hypothyroidism and has been prescribed levothyroxine. Which of the following medication instructions would the nurse include in the teaching?
- A. Take this medication before a meal or several hours after a meal.
- B. Take this medication during your morning meal.
- C. Take this medication with a full glass of water or fruit juice.
- D. Take this medication with high-protein foods.
Correct Answer: A
Rationale: The correct answer is A. Levothyroxine is best absorbed on an empty stomach, so taking it before a meal or several hours after a meal ensures optimal absorption. Taking it with food or certain beverages can interfere with absorption. Choice B is incorrect as taking it during a meal may reduce absorption. Choice C is incorrect as water or fruit juice is recommended, not required in full glass quantity. Choice D is incorrect as high-protein foods can also interfere with absorption.
While in group therapy,a nurse is caring for a client who has cancer and is scheduled for immediate chemotherapy. The client tells the nurse that she wants to try nontraditional treatments first. Which of the following responses should the nurse make?
- A. Your provider is very knowledgeable. If he prescribes chemotherapy, it's the best treatment for you.
- B. Using nontraditional treatments is not a good idea. I'd rather you avoid that route.
- C. Tell me more about your concerns about taking chemotherapy.
- D. A lot of people think nontraditional treatments will work, and they find out too late that they made the wrong choice.
Correct Answer: C
Rationale: Rationale: Option C is the correct response as it demonstrates active listening and empathy towards the client's concerns. By asking the client to elaborate on her reservations about chemotherapy, the nurse can better understand her perspective and provide tailored support and information. This approach promotes client autonomy and collaboration in decision-making.
Incorrect Choices:
A: This response dismisses the client's preferences and fails to address her concerns.
B: This response is judgmental and does not encourage open communication.
D: This response uses fear tactics and may cause distress to the client.
A nurse is caring for a newly admitted adolescent client. When asked to describe their social support system,the client responds My mom died last year, and I have been in foster care ever since. I don't have many friends. Which of the following actions should the nurse take?
- A. Tell the client that being in foster care can help with coping.
- B. Explain how grief support groups could increase coping and social support.
- C. Encourage the client to ask the provider for medication.
- D. Suggest using the internet as a source for finding supportive friends.
Correct Answer: B
Rationale: The correct answer is B. The nurse should explain how grief support groups could increase coping and social support. Grief support groups provide a safe space for individuals to share their experiences, receive empathy, and learn coping strategies. This is particularly important for the adolescent client who has experienced significant loss and lacks a strong social support system. By participating in a grief support group, the client can connect with others who have had similar experiences, feel understood, and build new supportive relationships. This intervention addresses the client's need for social support and coping mechanisms.
Choices A, C, and D are incorrect. A: Being in foster care may provide some support, but it does not address the client's specific need for coping with grief and building a social support system. C: Encouraging the client to ask for medication is not appropriate without first exploring non-pharmacological interventions. D: Suggesting the internet as a source for finding friends does not address the client's need for emotional support and may not