Nokea
An adult man believes that someone is poisoning his food. What is the best nursing action in response to this belief?
- A. Explain to him that no one is poisoning his food
- B. Tell him that the food is prepared in the hospital under secure conditions
- C. Taste his food to assure him that it is not being poisoned
- D. Offer him food that is in individual containers
Correct Answer: D
Rationale: Offering individually packaged food addresses the delusion non-confrontationally, reducing anxiety. Explaining, assuring, or tasting may escalate distrust.
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The nurse is caring for a client who is postoperative day 1 after a gastrectomy. Which of the following findings should the nurse report immediately?
- A. Pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Nasogastric tube output of 100 mL.
- D. Urine output of 40 mL/hour.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-gastrectomy complication. Options A, C, and D are normal.
If Ms. Barrett's distance vision is 20/30, which of the following statements is true?
- A. The client can read from 20' what a person with normal vision can read at 30'.
- B. The client can read from 30' what a person with normal vision can read at 20'.
- C. The client can read the entire chart from 30'.
- D. The client can read the chart from 20' with the left eye and from 30' with the right eye.
Correct Answer: A
Rationale: The numerator, which is always 20, is the distance in feet between the chart and the client. The denominator, which ranges from 10 to 200, indicates the distance at which a normal eye can read the chart.
An adult is being worked up for a possible duodenal ulcer. The nurse knows that which data, if present, would be most consistent with a duodenal ulcer?
- A. Two hours after his last meal, the client says, 'I need to feed my ulcer.'
- B. The client complains of epigastric pain a half hour after eating.
- C. The client has clay-colored stools.
- D. The client complains of pain beneath the right shoulder blade after eating.
Correct Answer: A
Rationale: Duodenal ulcers typically cause pain 2-3 hours after eating, relieved by food ('feeding the ulcer'), unlike pain immediately after eating (gastric ulcer), clay stools (biliary issues), or shoulder pain (gallbladder).
The nurse has just received report from the previous shift.
Which of the following patients should the nurse see FIRST?
- A. An elderly woman, 8-hours postoperative, following an open-reduction and internal fixation of the right hip.
- B. An elderly man admitted 4 hours ago with status asthmaticus.
- C. A middle-aged man admitted 2 days ago with pneumonia who has a temperature of 101.2°F (38.4°C).
- D. A middle-aged woman who suffered a myocardial infarction (MI) 3 days ago.
Correct Answer: B
Rationale: Strategy: Determine the least stable client. (1) leg needs to be abducted at all times, ice to operative site, turn patient as ordered (2) correct-life-threatening condition which can last longer than 24 hours, constantly monitor client (3) requires follow-up, assess breath sounds (4) monitor vital signs, I and O, teach to modify lifestyle (stop smoking, reduce stress, modify intake of calories, fat, and salt)
During the initial physical assessment on a client who is a Vietnamese immigrant, the nurse notices small, circular, ecchymotic areas on the client's knees. The best action for the nurse to take is to
- A. Ask the client for more information about the nature of the bruises
- B. Ask the client and then the family about the findings
- C. Report the bruising to social services to follow-up
Correct Answer: A
Rationale: Cupping' is practiced by Vietnamese. The principle is to create a vacuum inside a special cup by igniting alcohol-soaked cotton inside the cup. When the flame extinguishes, the cup is immediately applied to the skin of the painful site. The belief: the suction exudes the noxious element. The greater the bruise, the greater the seriousness of the illness.