Nokea
A thirty-seven year-old female in room 307 has a diagnosis of acquired immune deficiency syndrome (AIDS). Which of the following situations requires nurse intervention?
- A. A certified nursing assistant states, 'The patient in 307 is not wearing gloves shaving her legs.'
- B. A nursing assistant at the nursing station states, 'The patient in 307 has a respiratory rate of 16.'
- C. A nursing student in the cafeteria states, 'Dr. Jones told the patient in room 307 that she was going to die.'
- D. A certified nursing assistant states, 'Dr. Jones hasn't made rounds this morning.'
Correct Answer: C
Rationale: Patient confidentiality should be observed, especially in public places. The nurse should tell the nursing student do not discuss confidential information in public.
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The unlicensed assistive personnel (UAP) reports a sudden increase in temperature to 101 degrees Fahrenheit for a post surgical client. The nurse checks on the client's condition and observes a cup of steaming coffee at the bedside. What instructions are appropriate to give to the UAP?
- A. Encourage oral fluids to prevent dehydration
- B. Recheck temperature 15 minutes after removing hot liquids from the bedside
- C. Ask the client to drink only cold water and juices
- D. Chart this temperature elevation on the flow sheet
Correct Answer: B
Rationale: Recheck temperature to eliminate possible artificial elevation of temperature. Hot liquids, smoking, eating, chewing gum, and talking can all elevate temperature. Waiting to take the temperature for 15 minutes will help the temperature return to its normal, in order to get an accurate reading.
A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that
- A. such fantasies can gratify unconscious wishes or prepare for anticipated future events
- B. detaching or dissociating in this way postpones painful feelings
- C. converting or transferring a mental conflict to a physical symptom can lead to conflict within the partnership
- D. isolating the feelings in this way reduces conflict within the client and with others
Correct Answer: A
Rationale: such fantasies can gratify unconscious wishes or prepare for anticipated future events. Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratify unconscious wishes.
While the nurse is administering medications to a client, the client states 'I do not want to take that medicine today.' Which of the following responses by the nurse would be best?
- A. That's OK, its all right to skip your medication now and then.'
- B. I will have to call your doctor and report this.'
- C. Is there a reason why you don't want to take your medicine?'
- D. Do you understand the consequences of refusing your prescribed treatment?'
Correct Answer: C
Rationale: When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects.
A nurse has been ordered to administer Morphine to a patient. Which of the following effects is unrelated to Morphine's effects on the patient?
- A. Depressed function of the CNS
- B. Increased blood flow
- C. Decreased venous capacity
- D. Pain relief
Correct Answer: C
Rationale: Venous capacity increases with morphine use, not decreases, as it causes vasodilation.
The nurse is caring for a client in the late stages of Amyotrophic Lateral Sclerosis (ALS). Which of these pieces of equipment is the priority for the client to have access to in the home?
- A. A wheelchair
- B. A hospital bed with trapeze
- C. A communication board
- D. A suction machine
Correct Answer: C
Rationale: In late-stage ALS, clients often lose the ability to speak due to muscle weakness. A communication board is critical to ensure the client can express needs and maintain communication.