Nokea
A young female teenager describes a brutal assault and rape to the nurse on duty. Which of the following actions should the nurse take first?
- A. Check with case manager on duty about possible police intervention.
- B. Provide an environment of concern and emotional stabilization.
- C. Clean the patient's wounds with normal saline and gauze.
- D. Recommend a good attorney to the patient.
Correct Answer: B
Rationale: Emotional support is what that patient needs most at this point in time.
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Which of the following lab values might the nurse expect to see in a client with Addison's disease?
- A. WBC 10,000
- B. BUN 22
- C. $\mathrm{K}+3.5 \mathrm{mEq} / \mathrm{L}$
- D. $\mathrm{Na}+142 \mathrm{mEq} / \mathrm{L}$
Correct Answer: C
Rationale: Addison's disease causes hyperkalemia (elevated potassium, not 3.5 mEq/L, which is normal) and hyponatremia due to adrenal insufficiency.
An elderly client with glaucoma is scheduled for an exploratory laparotomy. Which of the following pre-op medications should be questioned?
- A. Demerol (meperidine)
- B. Atropine (atropine)
- C. Tagamet (cimetadine)
- D. Polycillin (ampicillin)
Correct Answer: B
Rationale: Atropine is contraindicated in glaucoma as it can increase intraocular pressure. Demerol , Tagamet , and Polycillin are generally safe in this context.
The nurse is teaching a client with a new diagnosis of osteoarthritis about celecoxib (Celebrex). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice
- B. Report any black, tarry stools
- C. Stop the medication if pain decreases
- D. Avoid regular joint exams
Correct Answer: B
Rationale: Black, tarry stools indicate gastroinTest inal bleeding, a serious celecoxib side effect. Options A, C, and D are incorrect: grapefruit juice is irrelevant, stopping the medication may not be advised, and exams are needed.
A six-month-old infant has had all of the required immunizations.
The nurse knows this would include which of the following?
- A. Two doses of diphtheria, tetanus, and pertussis vaccine.
- B. Measles, mumps, and rubella vaccines.
- C. A booster dose of the trivalent oral polio vaccine.
- D. Chickenpox and smallpox vaccines.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-first dose of the DPT may be given at two months, the second is given around four months (2) MMR is given at 15 months (3) polio is given at two and four months and again at 12 to 18 months (4) smallpox vaccine is no longer recommended
The nurse is developing a comprehensive care plan for a young woman with an eating disorder. The nurse refers this client to assertiveness skills classes. The nurse knows that this is an appropriate intervention because this client may have problems with
- A. aggressive behaviors and angry feelings.
- B. self-identity and self-esteem.
- C. focusing on reality.
- D. family boundary intrusions.
Correct Answer: B
Rationale: clients with eating disorders experience difficulty with self-identity and self-esteem, which inhibits their abilities to act assertively; some assertiveness techniques that are taught include giving and receiving criticism, giving and accepting compliments, accepting apologies, being able to say no, and setting limits on what they can realistically do rather than just doing what others want them to do