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A nurse manager is talking with a nurse who was unable to sleep the previous night after participating in an unsuccessful client resuscitation. Which of the following responses should the nurse manager make?
- A. Tell me what your concerns are.'
- B. Maybe you should schedule an appointment with a psychiatrist.'
- C. It's hard at first, but you will get used to these things.'
- D. Don't worry. We all go through these feelings. They will pass.'
Correct Answer: A
Rationale: Encouraging the nurse to express concerns supports emotional well-being and prevents burnout.
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A nurse is preparing to collect health history data during a client's admission. Which of the following questions should the nurse ask to promote this discussion?
- A. What brought you to the hospital?
- B. Would you tell me about all of your medical issues?
- C. Do you want to talk about your health concerns?
- D. Would it help to discuss your feelings about this hospitalization?
Correct Answer: A
Rationale: The correct answer is A: "What brought you to the hospital?" This question is open-ended and allows the client to share their reason for seeking care, which can provide valuable information for the nurse to understand the client's current health status and concerns. It also helps establish rapport and encourages the client to share their perspective.
Rationale for other choices:
B: Asking about all medical issues is too broad and may overwhelm the client, leading to a less focused discussion.
C: Asking if the client wants to talk about health concerns puts the onus on the client to bring up topics, which may hinder open communication.
D: While discussing feelings is important, it may not be the most immediate priority during admission and may not capture the primary reason for seeking care.
A nurse is collecting data for a client who has malnutrition resulting from a chronic illness. Which of the following manifestations should the nurse expect to find?
- A. Non-palpable spleen
- B. Slightly moist skin
- C. Presence of surface papillae on tongue
- D. Depigmented hair
Correct Answer: D
Rationale: The correct answer is D: Depigmented hair. Malnutrition can lead to changes in hair color, texture, and quality due to lack of essential nutrients. Depigmented hair is a common manifestation.
A: Non-palpable spleen is not directly related to malnutrition.
B: Slightly moist skin is not a typical manifestation of malnutrition.
C: Presence of surface papillae on the tongue may indicate other conditions, not specifically malnutrition.
A nurse is collecting data about a client's cranial nerves. Which of the following methods should the nurse use to identify a problem with cranial nerve II?
- A. Use a Snellen chart.
- B. Determine if the client's speech is hoarse.
- C. Present the client with mildly scented aromas.
- D. Ask the client to clench teeth.
Correct Answer: A
Rationale: The correct answer is A: Use a Snellen chart. Cranial nerve II, the optic nerve, is responsible for vision. By using a Snellen chart, the nurse can assess the client's visual acuity, which directly relates to the function of cranial nerve II. This method specifically targets the nerve in question and provides objective data on the client's vision.
Incorrect choices:
B: Determining if the client's speech is hoarse would assess cranial nerve X, the vagus nerve, responsible for speech and swallowing.
C: Presenting the client with scented aromas would assess cranial nerve I, the olfactory nerve, responsible for smell.
D: Asking the client to clench teeth would assess cranial nerve V, the trigeminal nerve, responsible for facial sensation and jaw movement.
A nurse is performing tracheostomy care for a client. Which of the following actions should the nurse take?
- A. Use medical aseptic technique.
- B. Clean the inner cannula with mild soap and water.
- C. Secure new tracheostomy ties before removing old ones.
- D. Apply petroleum jelly to the peristomal skin.
Correct Answer: C
Rationale: Securing new tracheostomy ties before removing old ones prevents accidental displacement. Medical asepsis is insufficient; sterile technique is required.
A nurse in a clinic is reinforcing teaching with a group of clients about preventing low back pain and injury. Which of the following statements should the nurse identify as an indication that the client requires further clarification?
- A. I'll sit with my knees lower than my hips.'
- B. I'll do exercises that strengthen my abdominal muscles.'
- C. I'll wear low-heeled shoes from now on.'
- D. I'll carry heavy objects close to my body.'
Correct Answer: A
Rationale: The correct answer is A: "I'll sit with my knees lower than my hips." This statement indicates a misunderstanding as it can actually contribute to low back pain. Sitting with knees lower than hips can increase pressure on the lower back. The correct sitting posture to prevent low back pain is to have knees at or slightly above hip level. This helps maintain the natural curve of the spine.
Explanation for other choices:
B: "I'll do exercises that strengthen my abdominal muscles." - Correct, as strong core muscles can help support the lower back.
C: "I'll wear low-heeled shoes from now on." - Correct, as high heels can alter posture and contribute to back pain.
D: "I'll carry heavy objects close to my body." - Correct, as this reduces strain on the back when lifting.