Nokea
An adult is almost ready for discharge. She has a complicated care regimen to follow. When conducting client teaching, the nurse notes that the client cannot recall basic information that was discussed the day before. The client also appears distracted. When asked if she is feeling comfortable about leaving the hospital, she states, 'There's just too much to learn. I know I'm going to get home and mess something up.' The nurse realizes that the client may be experiencing:
- A. mild anxiety.
- B. moderate anxiety.
- C. severe anxiety.
- D. panic anxiety.
Correct Answer: B
Rationale: Difficulty recalling information and expressed worry about managing care suggest moderate anxiety, impairing learning but not reaching panic.
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A client is receiving Vincristine (Marqibo). The client should be taught that the medication can:
- A. Cause diarrhea
- B. Change the color of her urine
- C. Cause mental confusion
- D. Cause changes in taste
Correct Answer: C
Rationale: Vincristine can cause neurotoxicity, including mental confusion. Diarrhea, urine color changes, and taste alterations are less common.
The nurse is new to the resident facility and is administering medications. One of the clients does not have a readable identification band in place. What should the nurse do?
- A. Ask the client what his name is
- B. Ask the client if he is Mr.
- C. Ask the roommate if this is Mr.
- D. Check the bed tag for the name
Correct Answer: C
Rationale: Asking the roommate provides a reliable secondary identifier in the absence of a readable ID band, ensuring safe medication administration. Self-identification or bed tags are less secure.
The nurse is caring for a client who is receiving an intravenous infusion. Which finding would indicate that the client's IV has infiltrated?
- A. The client's arm is red and warm to the touch.
- B. The IV is running faster than the desired rate.
- C. The area around the infusion site is pale and cool to the touch.
- D. The client complains of severe pain up and down the arm.
Correct Answer: C
Rationale: Infiltration causes pale, cool skin around the IV site due to fluid leakage into tissues. Redness, fast infusion, or radiating pain suggest other issues.
Which of the following beverages is most appropriate for a client with renal failure?
- A. Prune juice
- B. Grape juice
- C. Apple juice
- D. Apricot juice
Correct Answer: C
Rationale: Apple juice is most appropriate for a client with renalrape juice has a lower potassium content, which is crucial for renal failure patients who need to limit potassium intake. Prune, grape, and apricot juices are high in potassium, which can be harmful in renal failure.
The nurse on the mental health unit is caring for assigned clients. The nurse should first check the client with
- A. obsessive-compulsive disorder who has spent the past hour counting socks
- B. major depressive disorder who has consumed no food from the past 2 meal trays
- C. posttraumatic stress disorder who reports a depressed mood and feelings of hopelessness
- D. bipolar I disorder who is experiencing an acute manic episode and reports sleeping 4 hours last night
Correct Answer: C
Rationale: Hopelessness and depressed mood in PTSD indicate suicide risk, requiring immediate assessment. OCD behavior , poor intake , and mania are less urgent but still need attention.