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A woman in her third trimester complains of severe heartburn. What is appropriate teaching by the nurse to help the woman alleviate these symptoms?
- A. Drink small amounts of liquids frequently
- B. Eat the evening meal just before retiring
- C. Take sodium bicarbonate and water after each meal
- D. Sleep with head propped on several pillows
Correct Answer: D
Rationale: Sleep with head propped on several pillows. Heartburn is a burning sensation caused by regurgitation of gastric contents. It is best relieved by sleeping position, eating small meals, and not eating before bedtime.
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The nurse is caring for a client with schizophrenia who is experiencing visual hallucinations. The client states, 'There is a bad person standing in my room.' Which of the following responses would be most appropriate for the nurse to make?
- A. Your illness is making you experience visual hallucinations.'
- B. I know you are frightened, but I do not see anyone in your room.'
- C. Do not worry. I will give you medication that will make the bad person go away.'
- D. We will go into the dayroom and play a game. I know you like to play board games.'
Correct Answer: B
Rationale: When addressing hallucinations, the nurse should acknowledge the client’s fear while gently reinforcing reality. Response B validates the client’s emotions and clarifies that the nurse does not see the hallucination, maintaining trust without reinforcing the delusion. Labeling the hallucination as part of the illness (A) may confuse or alienate the client. Promising medication will resolve it (C) oversimplifies treatment, and distracting with games (D) dismisses the client’s distress.
The nurse is providing first aid at an outdoor festival when a client reports dizziness and weakness. The client is flushed, sweating, nauseated, and slightly tachycardic. Which action is most appropriate at this time?
- A. Call emergency medical services and place ice packs on the client’s axilla and groin
- B. Encourage the client to leave the venue to visit a health care provider
- C. Evaluate whether the client may be intoxicated
- D. Move the client to an air-conditioned booth and provide a cool sports drink
Correct Answer: D
Rationale: Symptoms suggest heat exhaustion. Moving to a cool area and providing fluids (D) is the first step. EMS (A) is premature, leaving (B) delays care, and intoxication (C) is not indicated.
A Hispanic client confides in the nurse that she is concerned that staff may give her newborn the 'evil eye.' The nurse should communicate to other personnel that the appropriate approach is to
- A. Touch the baby after looking at him
- B. Talk very slowly while speaking to him
- C. Avoid touching the child
- D. Look only at the parents
Correct Answer: A
Rationale: In many cultures, an 'evil eye' is cast when looking at a person without touching him. Thus, the spell is broken by touching while looking or assessing.
Prior to administering a tube feeding, the nurse obtains 50 mL of aspirant. The nurse should:
- A. Discard the aspirant and begin the tube feeding.
- B. Replace the aspirant and begin the tube feeding.
- C. Discard the aspirant and hold the tube feeding.
- D. Replace the aspirant and hold the tube feeding.
Correct Answer: B
Rationale: Replacing the aspirant prevents fluid/electrolyte loss, and feeding can proceed if pH confirms placement. Discarding aspirant risks dehydration, and holding the feeding is unnecessary unless placement is uncertain.
The nurse is caring for a client with anorexia nervosa. Which of the following findings would be consistent with the condition? Select all that apply.
- A. Heat intolerance
- B. Has not menstruated in 3 months
- C. Avoids participation in physical activity
- D. Fine, downy hair on the face and back
- E. Decreased serum potassium level
- F. BMI of 16 kg/m²
Correct Answer: B,D,E,F
Rationale: Anorexia nervosa is characterized by severe weight loss and malnutrition, leading to specific clinical findings. Amenorrhea (B) results from hormonal imbalances due to low body fat. Lanugo (D), fine downy hair, develops as a compensatory mechanism for heat loss. Hypokalemia (E) occurs due to starvation or purging behaviors. A BMI of 16 kg/m² (F) indicates severe underweight status, consistent with anorexia. Heat intolerance (A) is more typical of hyperthyroidism, and avoiding physical activity (C) is incorrect as clients often engage in excessive exercise.