Nokea
A nurse wants to develop a therapeutic relationship with an anxious new client. Which of the following is an open-ended question?
- A. Do you think your anxiety medication has been helping?'
- B. Does anyone in your family have anxiety or depression?'
- C. How is your anxiety on the weekends when you are off work?'
- D. So you are saying that your trouble sleeping started right around the time you started a new job?'
Correct Answer: C
Rationale: Open-ended questions encourage elaboration, like 'How is your anxiety on the weekends?' Others are closed-ended or reflective statements.
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The nurse is teaching a client with a new diagnosis of atrial fibrillation about warfarin (Coumadin) therapy. Which of the following statements by the client indicates a need for further teaching?
- A. I will avoid eating large amounts of spinach.
- B. I will report any signs of bleeding to my doctor.
- C. I will take my medication at the same time each day.
- D. I will stop taking the medication if I feel dizzy.
Correct Answer: D
Rationale: warfarin should not be stopped without medical advice, as it increases the risk of clotting
A client is recovering from a stroke and the nurse is doing range-of-motion exercises. Which movements should be included for ROM of the elbow on the weak side? Select all that apply.
- A. Abduction and adduction
- B. Hyperextension
- C. Supination and pronation
- D. Flexion and extension
- E. Rotation
Correct Answer: C,D
Rationale: Elbow ROM includes supination/pronation (C) and flexion/extension (D). Abduction/adduction (A), hyperextension (B), and rotation (E) are not applicable to the elbow joint.
The nurse is reflecting on the client-nurse relationship. Which statement is correct regarding the orientation (introductory) phase of the relationship?
- A. identifying the client's strengths and limitations
- B. promoting the client's insight and perception of reality
- C. continuously evaluating progress toward the client's goals
- D. exploring feelings about the termination phase of the relationship
Correct Answer: A
Rationale: The orientation phase focuses on establishing trust and identifying the client’s strengths and limitations to guide care.
The client returns to the recovery room following repair of an abdominal aneurysm. Which finding would require further investigation?
- A. Pedal pulses regular
- B. Urinary output 20 mL in the past hour
- C. Blood pressure 108/50
- D. Oxygen saturation 97%
Correct Answer: B
Rationale: Low urinary output (20 mL/hour) may indicate renal impairment or hypoperfusion, requiring further investigation.
The nurse caring for a client with chest tubes notes that the Pleuravac's collection chambers are full. The nurse should:
- A. Add more water to the suction-control chamber
- B. Remove the drainage using a 60 mL syringe
- C. Milk the tubing to facilitate drainage
- D. Prepare a new unit for continuing collection
Correct Answer: D
Rationale: When the Pleuravac collection chambers are full, a new unit is needed to continue effective drainage and maintain the closed system.