Nokea
A nurse on a medical-surgical unit receives a telephone call from an individual who identifies himself as the client's employer. The employer asks the nurse about the client's condition. Which of the following is an appropriate response by the nurse?
- A. The client's condition is stable right now.
- B. I will tell him you called.
- C. I cannot confirm or deny that we have a client by that name.
- D. He is here in the hospital, but I cannot tell you anything else.
Correct Answer: C
Rationale: This response protects confidentiality under HIPAA by not disclosing client presence.
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A nurse is checking for proper placement of a feeding tube. Which of the following methods is the most reliable for verification of tube placement?
- A. Verify the bilirubin level of the tube contents.
- B. Check the pH level of gastric contents.
- C. Auscultate for air insufflation.
- D. Request a chest x-ray.
Correct Answer: D
Rationale: A chest x-ray visually confirms tube placement, the most reliable method.
A nurse is participating in a group discussion about complicated grief associated with loss. Which of the following should the nurse identify as an example of exaggerated grief?
- A. A client whose grief response is repressed.
- B. A client whose grief response begins following a terminal diagnosis.
- C. A client whose grief response leads to self-destructive behaviors.
- D. A client whose grief response is triggered by a secondary loss.
Correct Answer: C
Rationale: Exaggerated grief involves intense, harmful reactions like self-destructive behaviors, impairing function.
A nurse is reinforcing teaching with a client who is perimenopausal. Which of the following statements by the client indicates an understanding of the teaching?
- A. I might have headaches due to a decline in my estrogen levels.
- B. I should stop receiving Papanicolaou tests once I reach menopause.
- C. I can expect to have regular periods until I am in menopause.
- D. The best time to perform a breast self-examination is on the first day of my period.
Correct Answer: A
Rationale: Declining estrogen can cause headaches, reflecting perimenopause symptoms.
A nurse is planning to provide postmortem care for a client who requires an autopsy. Which of the following actions should the nurse plan to take?
- A. Place an identification tag on the outside of the client's shroud.
- B. Ask the assistive personnel to document the client's time of death.
- C. Wear sterile gloves when cleaning the client's body.
- D. Remove the client's dentures and give them to the client's family.
Correct Answer: A
Rationale: An ID tag ensures proper identification for autopsy purposes.
A nurse is reinforcing teaching about seizure management with the family of a client who has a seizure disorder. Which of the following statements by a family member indicates an understanding of the teaching?
- A. I will turn him on his back during seizures.
- B. I will gently restrain him during seizures.
- C. I will loosen his clothing during seizures.
- D. I will insert a washcloth in his mouth during seizures.
Correct Answer: C
Rationale: Loosening clothing ensures comfort and breathing, a safe seizure management step.