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An adolescent male was in an accident and is hospitalized with multiple fractures. The nurse enters the room and observes that he has his back to the door and is staring at the wall with a sad expression on his face. What is the best response for the nurse to make at this time?
- A. You seem sad.'
- B. Don't be too down on yourself.'
- C. I know it is hard to be out of school.'
- D. Do you miss your family and friends?'
Correct Answer: A
Rationale: Acknowledging the client's sadness ('You seem sad') is therapeutic, encouraging expression of feelings. Other responses assume causes or dismiss emotions, which are less supportive.
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Which nursing instruction is most beneficial to minimize stress on the client's painful joints?
- A. Maintain a normal weight.
- B. Apply a topical analgesic cream.
- C. Take a calcium supplement.
- D. Become more physically active.
Correct Answer: A
Rationale: Maintaining normal weight reduces joint stress, especially in osteoarthritis.
The nurse supervises a nursing assistant who is applying the client's antiembolism stockings. What is the correct technique for applying these stockings?
- A. The nursing assistant applies the stockings before getting the client out of bed.
- B. The nursing assistant applies the stockings just before helping the client do leg exercises.
- C. The nursing assistant applies the stockings after nursing that the client's legs are cool.
- D. The nursing assistant applies the stockings at night before the client's bedtime.
Correct Answer: A
Rationale: Applying antiembolism stockings before the client gets out of bed ensures compression is in place during upright positions when venous pooling is most likely. Applying them later or based on leg temperature is less effective.
The nurse is caring for clients on a surgical unit. Which nursing task is most appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP)?
- A. Help the client with a two (2)-day postop amputation put on the prosthesis.
- B. Request the UAP double-check a unit of blood to be hung.
- C. Change the surgical dressing on the client with a Syme's amputation.
- D. Ask the UAP to take the client to the physical therapy department.
Correct Answer: D
Rationale: Transporting a client to PT is within UAP scope. Prosthesis application, blood verification, and dressing changes require nursing judgment.
What is the most important factor for the nurse to consider when teaching the child who has CP?
- A. Current age
- B. Type of cerebral palsy
- C. Prior illness experience
- D. Developmental level
Correct Answer: D
Rationale: Developmental level is critical to tailor teaching to the child's cognitive and physical abilities.
Which foods should the nurse recommend to a client when discussing sources of dietary calcium?
- A. Yogurt and dark-green, leafy vegetables.
- B. Oranges and citrus fruits.
- C. Bananas and dried apricots.
- D. Wheat bread and bran.
Correct Answer: A
Rationale: Yogurt and dark-green leafy vegetables (e.g., kale) are rich in calcium, supporting bone health. Other options have minimal calcium content.