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A nurse is instructing a patient on the order of sensations with the application of an ice water bath for a swollen right ankle. Which of the following is the correct order of sensations experienced with an ice water bath?
- A. cold, burning, aching, and numbness
- B. burning, aching, cold, and numbness
- C. aching, cold, burning and numbness
- D. cold, aching, burning and numbness
Correct Answer: A
Rationale: CBAN, cold, burn, ache, numbness
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The nurse is caring for a dying client who has persistently requested that the nurse 'help her to die and be in peace.' According to the Code of Ethics for Nurses, the nurse should:
- A. Ask the client whether she has signed the advance directives document.
- B. Tell the client that he or she will ask another nurse to care for her.
- C. Instruct the client that only a physician can legally assist a suicide.
- D. Try to make the client as comfortable as possible, but refuse to assist in death.
Correct Answer: D
Rationale: Try to make the client as comfortable as possible but refuse to assist in death. One of the competencies necessary for nurses to have in giving high quality care to clients/families during the end of life care is: apply legal and ethical principles in the analysis of complex issues and end-of-life care, recognizing the influence of personal values, profession codes, and client preferences.
A female client complains to the nurse at the health department that she has fatigue, shortness of breath, and lightheadedness. Her history reveals no significant medical problems. She states that she is always on a fad diet without any vitamin supplements. Which tests should the nurse expect the client to have first?
- A. peptic ulcer studies
- B. complete blood count, including hematocrit and hemoglobin
- C. genetic testing
- D. hemoglobin electrophoresis
Correct Answer: B
Rationale: The initial tests to determine the basis for her symptoms (considering her fad dieting) should be a complete blood count, urinalysis, blood sugar, and other tests. The decision about further testing is then made based on these results, her history, and other factors.
What is the reason for a contract between nurse and client?
- A. Contracts state the roles the participants take.
- B. Contracts are indicative of the feeling tone established between participants.
- C. Contracts are binding and prevent either party from ending the relationship prematurely.
- D. Contracts spell out the participation and responsibilities of both parties.
Correct Answer: D
Rationale: A contract emphasizes that the nurse works with the client, rather than doing something for the client. Working with suggests that each party is expected to participate and share responsibility for outcomes. Contracts do not, however, stipulate roles or feeling tone, nor is premature termination expressly forbidden.
The nurse wishes to decrease a client's use of denial and increase the client's expression of feelings. To do this the nurse should:
- A. tell the client to stop using the defense mechanism of denial.
- B. positively reinforce each expression of feelings.
- C. instruct the client to express feelings.
- D. challenge the client each time denial is used.
Correct Answer: B
Rationale: The nurse should positively reinforce each expression of feelings.
A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?
- A. temperature of 102°F and a productive cough
- B. arterial blood gases (ABGs) with a PaO2 of 92 and PaCO2 of 40 mmHg
- C. trachea deviating to the right
- D. barrel-chested appearance
Correct Answer: C
Rationale: A mediastinal shift is indicative of a tension pneumothorax along with the other symptoms in the question. Because the individual was involved in an MVA, assessment is targeted at acute traumatic injuries to the lungs, heart, or chest wall rather than other conditions indicated in the other choices.