Nokea
A young adult female client is seen in the emergency department for a minor injury following a motor vehicle collision. She states she is very angry at the person who hit her car. What is the best nursing response?
- A. You are lucky to be alive. Be grateful no one was killed.'
- B. I understand your car was not seriously damaged.'
- C. You are upset that this incident has brought you here.'
- D. Have you ever been in the emergency department before?'
Correct Answer: C
Rationale: The correct answer is C: "You are upset that this incident has brought you here." This response acknowledges the client's feelings of anger and validates her emotions, showing empathy and understanding. It demonstrates active listening and therapeutic communication, which is crucial in building trust and rapport with the client.
Choice A is incorrect as it dismisses the client's feelings of anger and invalidates her emotions by shifting the focus to being grateful instead. Choice B is incorrect as it minimizes the client's emotional response by focusing on the material aspect of the situation rather than addressing her feelings. Choice D is incorrect as it does not address the client's emotional state and is a closed-ended question that does not encourage further discussion or exploration of the client's feelings.
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A client with a history of chronic obstructive pulmonary disease (COPD) presents with increasing shortness of breath. Which assessment finding is most important for the nurse to report to the healthcare provider?
- A. Barrel-shaped chest.
- B. Use of accessory muscles to breathe.
- C. Oxygen saturation of 88%.
- D. Respiratory rate of 22 breaths per minute.
Correct Answer: C
Rationale: The correct answer is C: Oxygen saturation of 88%. In COPD patients, low oxygen saturation indicates inadequate gas exchange and potential respiratory distress. Oxygen saturation below 90% requires immediate intervention to prevent hypoxemia. A: Barrel-shaped chest is a common finding in COPD due to hyperinflation, but it is not a critical indicator of acute exacerbation. B: Use of accessory muscles suggests increased work of breathing but may not be as urgent as low oxygen saturation. D: Respiratory rate is within normal range, so it is less concerning than the low oxygen saturation.
A patient with hypertension is prescribed lisinopril. What side effect should the nurse monitor for?
- A. Hyperkalemia
- B. Hypoglycemia
- C. Bradycardia
- D. Constipation
Correct Answer: A
Rationale: The correct answer is A: Hyperkalemia. Lisinopril is an ACE inhibitor that can cause potassium retention, leading to hyperkalemia. Monitoring potassium levels is crucial to prevent serious complications like cardiac arrhythmias. Hypoglycemia (B) is not a common side effect of lisinopril. Bradycardia (C) and constipation (D) are also not typically associated with lisinopril use. Hyperkalemia is the most critical side effect to monitor in this case.
A patient with depression is prescribed fluoxetine. What is an important side effect for the nurse to monitor?
- A. Weight gain
- B. Bradycardia
- C. Dry mouth
- D. Suicidal thoughts
Correct Answer: D
Rationale: The correct answer is D: Suicidal thoughts. When a patient with depression is prescribed fluoxetine, there is a risk of increased suicidal thoughts, especially in the initial weeks of treatment. This is important for the nurse to monitor because it can lead to serious consequences. Weight gain (A) is a common side effect of fluoxetine but not as critical to monitor as suicidal thoughts. Bradycardia (B) and dry mouth (C) are not common side effects of fluoxetine and are less relevant to monitor in this scenario. Monitoring for suicidal thoughts is crucial for patient safety.
While assessing a client with diabetes mellitus, the nurse observes an absence of hair growth on the client's legs. What additional assessment provides further data to support this finding?
- A. Palpate for the presence of femoral pulses bilaterally.
- B. Assess for the presence of a positive Homan's sign.
- C. Observe the appearance of the skin on the client's legs.
- D. Watch the client's posture and balance during ambulation.
Correct Answer: C
Rationale: The correct answer is C: Observe the appearance of the skin on the client's legs. In clients with diabetes mellitus, poor circulation can lead to decreased hair growth on the legs. By observing the skin appearance, the nurse can look for signs of poor circulation such as dry skin, thinning of the skin, or discoloration. This assessment provides further data to support the finding of absent hair growth.
Choices A, B, and D are incorrect because they do not directly relate to the assessment of absent hair growth in clients with diabetes mellitus. Palpating for femoral pulses assesses circulation but does not specifically address the absence of hair growth. Assessing for Homan's sign evaluates for deep vein thrombosis, which is not directly related to hair growth. Watching posture and balance during ambulation assesses mobility and stability but does not provide information on hair growth or circulation in the legs.
A patient with chronic pain is prescribed a fentanyl patch. What is the most important instruction for the nurse to provide?
- A. Apply the patch to a different site each time.
- B. Change the patch every 72 hours.
- C. Avoid using additional heating pads over the patch.
- D. Remove the patch before showering.
Correct Answer: B
Rationale: The correct answer is B: Change the patch every 72 hours. Fentanyl patches are typically designed to be worn for 72 hours before being replaced to maintain consistent pain relief. Changing the patch on time helps prevent withdrawal symptoms and ensures the effectiveness of the medication.
A: Applying the patch to a different site each time is important to prevent skin irritation but is not the most crucial instruction.
C: Avoiding heating pads over the patch is important to prevent overheating and excessive absorption of the medication, but changing the patch timely is more critical.
D: Removing the patch before showering is not necessary as fentanyl patches are designed to be water-resistant.