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A woman is receiving outpatient treatment at a mental health center. She starts crying and tells the nurse her husband has filed for divorce. The best response from the nurse is
- A. I am so sorry. I am divorced too, but it worked out for the best.'
- B. About half of marriages end in divorce these days.'
- C. You have to let him go and move on with your life.'
- D. Tell me what happened.'
Correct Answer: D
Rationale: An open-ended response like 'Tell me what happened' encourages the client to express feelings, fostering therapeutic communication.
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An ICU nurse monitors a client recovering from a head injury. The client's intracranial pressure (ICP) has been between 15 and 19 mmHg throughout the shift. However, after the nurse suctions the client's endotracheal tube, the ICP jumps to 28 mmHg. It decreases a few minutes later to 20 mmHg. The best intervention by the nurse is to
- A. increase the rate of the sedative IV drip.
- B. chart the findings and continue to monitor the client.
- C. reposition the client.
- D. contact the physician.
Correct Answer: D
Rationale: A sudden ICP spike to 28 mmHg post-suctioning suggests a significant issue (e.g., impaired cerebral perfusion). The physician should be contacted for evaluation.
The client pulls out the chest tube and fails to report the occurrence to the nurse. When the nurse discovers the incidence, he should take which initial action?
- A. Order a chest x-ray
- B. Reinsert the tube
- C. Cover the insertion site with a Vaseline gauze
- D. Call the doctor
Correct Answer: C
Rationale: Covering the insertion site with Vaseline gauze prevents air entry into the pleural space, stabilizing the client until further intervention.
Which of the following statements describes Piaget's stage of concrete operations?
- A. Reflex activity proceeds to imitative behavior.
- B. The ability to see another's point of view increases.
- C. Thought processes become more logical and coherent.
- D. The ability to think abstractly leads to logical conclusion.
Correct Answer: C
Rationale: Piaget's concrete operations stage (ages 7-11) is characterized by logical and coherent thought processes, enabling problem-solving with concrete objects.
A client is admitted complaining of chest pain. Which of the following drug orders should the nurse question?
- A. Nitroglycerin
- B. Ampicillin
- C. Propranolol
- D. Verapamil
Correct Answer: B
Rationale: Ampicillin, an antibiotic, is not indicated for chest pain, which is typically cardiac-related and treated with nitroglycerin, propranolol, or verapamil.
The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client:
- A. You may be electrocuted if you use water with this unit.'
- B. Please report skin irritation to the doctor.'
- C. The unit may be used anywhere on the body without fear of adverse reactions.'
- D. A cream should be applied to the skin before applying the unit.'
Correct Answer: B
Rationale: Skin irritation is a common side effect of TENS; reporting it ensures timely management.