Nokea
A woman calls the physician's office stating that her 16-year-old daughter took 20 or 30 sleeping pills. The mother tells the nurse that her daughter is awake and says, 'Leave me alone. I just want to die.' How should the nurse respond?
- A. Ask her why she wants to die.'
- B. Try to convince her that she wants to live.'
- C. Give her a glass of milk to bind the medication.'
- D. Call 911 and get her to the closest emergency room immediately.'
Correct Answer: D
Rationale: A suicide attempt with sleeping pills requires immediate emergency care to prevent overdose complications. Other responses delay critical intervention.
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The nurse is working on a plan to assist an abused client back into the work situation. Which will likely be most helpful in decreasing the trauma for the client?
- A. Support from significant others
- B. Support from a counselor
- C. Support from friends
- D. Support from coworkers
Correct Answer: A
Rationale: Support from significant others provides emotional stability, most effective in reducing trauma for an abused client re-entering work.
A postoperative appendectomy client who is complaining of incisional pain. A diabetic client who had a cardiac catheterization in the early AM. A postoperative cholecystectomy client who is complaining of incisional pain. A client with congestive heart failure who underwent diuresis in the hospital.
The nurse is planning discharge for a group of clients. It is MOST important to refer which of the following clients for home care?
- A. A postoperative appendectomy client who is complaining of incisional pain.
- B. A diabetic client who had a cardiac catheterization in the early AM.
- C. A postoperative cholecystectomy client who is complaining of incisional pain.
- D. A client with congestive heart failure who underwent diuresis in the hospital.
Correct Answer: D
Rationale: Strategy: Determine the least stable client. Remember the ABCs. (1) expected outcome, treat with analgesics (2) instruct no bending, straining, or lifting heavy objects for 24 hours, observe for bleeding, swelling, new bruising at puncture site (3) expected outcome, treat with analgesics (4) correct-assess for decreased circulating volume, hypotension, tachycardia, monitor for signs and symptoms of hypokalemia
An adult who is on an American Dietetic Association (ADA) diabetic diet tells the nurse that she will not eat the asparagus that is on her tray. What would be an appropriate substitute for the nurse to offer?
- A. Broccoli
- B. Corn
- C. Peas
- D. Beets
Correct Answer: A
Rationale: Broccoli, like asparagus, is a non-starchy vegetable, fitting the ADA diabetic diet's emphasis on low-glycemic foods. Corn, peas, and beets are higher in carbohydrates.
The nurse is making assignments for the day. The staff consists of an RN, an LPN, and a nursing assistant. Which client should be assigned to the nursing assistant?
- A. A client with laparoscopic cholecystectomy
- B. A client with viral pneumonia
- C. A client with suspected ectopic pregnancy
- D. A client with intermittent chest pain
Correct Answer: B
Rationale: A nursing assistant can provide basic care such as hygiene and vital signs for stable clients. A client with viral pneumonia, if stable, requires less complex care compared to post-surgical , potential emergency , or cardiac clients, which require licensed staff.
A child in the waiting room who can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet.
The nurse identifies the child's chronological age to be
- A. 1 year old.
- B. 2 years old.
- C. 3 years old.
- D. 5 years old.
Correct Answer: C
Rationale: Strategy: Picture the child at each age. (1) unable to walk up and down stairs with hand held until 18 months (2) unable to jump until 30 months (3) correct-able to jump with both feet and stand on one foot momentarily at 30 months (4) behaviors are seen in younger child