Nokea
An adult asks the nurse what could be causing him to have a black tongue and black stools. The following items are in the client's history. Which is most likely to be causing his symptoms?
- A. He is taking bismuth subsalicylate (Pepto-Bismol) for loose stools.
- B. He has been eating a lot of beets and broccoli recently.
- C. He has been taking iron tablets for anemia.
- D. He eats a lot of red meat.
Correct Answer: A
Rationale: Bismuth subsalicylate commonly causes black tongue and stools, a harmless side effect, unlike the other options.
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A 4 year-old hospitalized child begins to have a seizure while playing with hard plastic toys in the hallway. Of the following nursing actions, which one should the nurse do first?
- A. Place the child in the nearest bed
- B. Administer IV medication to slow down the seizure
- C. Place a padded tongue blade in the child's mouth
- D. Remove the child's toys from the immediate area
Correct Answer: D
Rationale: Remove the child's toys from the immediate area. Nursing care for a child having a seizure includes, maintaining airway patency, ensuring safety, administering medications, and providing emotional support. Since the seizure has already started, nothing should be forced into the child's mouth and the child should not be moved. Of the choices given, the first priority would be to provide a safe environment.
The nurse is talking with the parents of an adolescent client who was brought to the emergency department after making superficial cuts on the arms with a razor blade. There are several cuts in various stages of healing on the client’s forearms. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
- A. This must be difficult for you
- B. Everything is going to be alright
- C. We have cleaned and bandaged the cuts
- D. Why did you wait until now to bring your child here?
- E. Tell me about when you started noticing this behavior
Correct Answer: A,C,E
Rationale: Acknowledging difficulty, confirming care, and exploring behavior onset are supportive and therapeutic. Assuring everything will be alright is dismissive, and questioning delay is judgmental.
An elderly war veteran with prostate cancer and coronary artery disease is hospitalized for urosepsis. The client becomes angry with one of the unlicensed assistive personnel (UAP) who is trying to help the client bathe. Later, the UAP expresses frustration with the client to the nurse. Which statement would be the most appropriate response?
- A. I’ll talk with the client to see why the client is angry
- B. It sounds like you shouldn’t work with this client, so I will reassign you
- C. Let’s go together to ask about the client’s concerns
- D. Why don’t you go talk with the client about why the client is angry?
Correct Answer: C
Rationale: Going together to address concerns promotes teamwork, de-escalates conflict, and ensures the client’s needs are met. Individual talks risk miscommunication, and reassignment avoids resolution.
The nurse is caring for a client with diabetic ketoacidosis (DKA). Which of the following acid-base imbalances would the nurse expect to assess in this client?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: DKA causes metabolic acidosis due to excess ketone production from fat breakdown. Alkalosis and respiratory imbalances are not typical in DKA.
The nurse on a pediatric unit is caring for a 2-year-old client. Which of the following interventions are appropriate to reduce the distress of hospitalization on the child? Select all that apply.
- A. Encourage the parent to leave the child alone for short intervals
- B. Follow the child’s home sleep schedule and routine
- C. Integrate preferred snack foods into the child’s routine
- D. Point out body changes that may occur
- E. Provide various options when choosing toys
Correct Answer: B,C,E
Rationale: Maintaining sleep routines, offering preferred snacks, and providing toy choices reduce distress by promoting familiarity and autonomy. Leaving alone or discussing body changes may increase anxiety.