Nokea
A young adult patient constantly seeks attention from the nurses, stomping away from the nurses’ station and pouting when her requests are refused.
- A. What is the most appropriate response by the nurse to a young adult patient exhibiting attention-seeking behavior?
- B. Have the patient establish trust with one staff person with whom therapeutic interventions should occur.
- C. Give the patient unsolicited attention when she is not exhibiting the unacceptable behaviors.
- D. Ignore the patient when she exhibits attention-seeking behavior.
- E. Rotate the staff so the patient will learn to relate to more than one nurse.
Correct Answer: B
Rationale: Rewarding non-attention-seeking behaviors with unsolicited attention reinforces positive behavior. Ignoring the patient or rotating staff does not address the behavior constructively, and assigning one staff member reduces consistency in approach.
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An 87-year-old woman is admitted to the acute care hospital for heart failure. The nurse asks about the client's signs and symptoms and obtains vital signs. Considering the client's age, what additional question is most important for the nurse to ask?
- A. How do you manage your bowels?
- B. When was your last menstrual period?
- C. What are your favorite foods?
- D. When was your last tetanus shot?
Correct Answer: D
Rationale: Elderly patients are at risk for tetanus due to waning immunity; assessing vaccination status is critical for infection prevention.
The physician prescribes estrogen (Premarin) 0.625 mg daily for a 43-year-old woman. The nurse knows which of the following symptoms is a common initial side effect of this medication?
- A. Nausea.
- B. Visual disturbances.
- C. Tinnitus.
- D. Ataxia.
Correct Answer: A
Rationale: common at breakfast time; will subside after weeks of medication use; take after eating to reduce incidence
In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and
- A. Increased retention of albumin in the vascular system
- B. Decreased colloidal osmotic pressure in the capillaries
- C. Fluid shift from interstitial spaces into the vascular space
- D. Reduced tubular reabsorption of sodium and water
Correct Answer: B
Rationale: Decreased colloidal osmotic pressure in the capillaries. Loss of albumin reduces osmotic pressure, causing edema.
A client chief complaint in a nursing health history.
Which of the following is an example of a properly recorded client chief complaint in a nursing health history?
- A. Complains of midepigastric discomfort with flatus after meals.'
- B. Area above umbilicus appears to be painful and tender to palpation.'
- C. My stomach hurts after dinner every night.'
- D. Rebound tenderness present in mid-to-upper abdominal area.'
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) incorrectly stated (2) objective finding (3) correct-chief complaint should be recorded using the client's own words (4) objective finding
A 34-year-old multipara comes to the prenatal clinic during her fifth month of pregnancy. The client complains to the nurse that her breasts are sensitive and sore.
Which of the following suggestions by the nurse is BEST?
- A. Apply warm compresses to your breasts and take two aspirin as needed.
- B. Massage your breasts with lotion and wear loose-fitting clothing.
- C. Apply cold compresses to your breasts and wear a well-fitting, supportive bra.
- D. Take a diuretic once a day and avoid touching your breasts.
Correct Answer: C
Rationale: Strategy: 'BEST' indicates priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) would increase circulation and increase discomfort, should avoid taking medications (2) not effective in decreasing discomfort (3) correct-during pregnancy there is an increase in lactiferous ducts and lobule-alveolar tissue (4) medications are to be avoided during pregnancy