Nokea
An advantage of mutual pretense at the end of life for the client is that it allows the client:
- A. To fully employ the ego defense mechanism of denial at the end of life.
- B. To exercise control over loved ones when they are at the end of life.
- C. To fully employ the ego defense mechanism of projection at the end of life.
- D. To preserve a degree of dignity and privacy at the end of life.
Correct Answer: D
Rationale: Mutual pretense allows clients to preserve dignity and privacy (D) by avoiding open acknowledgment of death, maintaining emotional comfort. Denial (A) and projection (C) are not the primary mechanisms, and control over loved ones (B) is not the focus.
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The nurse is reviewing tasks for assigned clients. Which action is a priority to implement?
- A. Visual acuity test for a client reporting blurred vision in one eye.
- B. 12-lead electrocardiogram for a client reporting chest pain.
- C. Orthostatic vital signs for a client complaining of syncope.
- D. Discharge teaching for a client newly diagnosed with hypertension.
Correct Answer: B
Rationale: A 12-lead ECG for chest pain (B) is the priority to rule out life-threatening cardiac events like myocardial infarction. Blurred vision (A), syncope (C), and discharge teaching (D) are less urgent, as they are not immediately life-threatening.
A 30-year old patient presents to the Emergency Department with alcohol withdrawal seizures. The psychiatry nurse understands that the patient will soon be admitted to the non-medical psychiatric care unit. To keep this patient safe, the nurse must perform which priority nursing action?
- A. Ask the physician for a clonazepam prescription, an anxiolytic that may help with the withdrawal symptoms.
- B. Ensure that a working IV pump is set up at the patient's bedside.
- C. Order a STAT arterial blood gas (ABG).
- D. Pad the side rails of the patient's assigned bed.
Correct Answer: D
Rationale: Padding the side rails (D) is the priority to prevent injury during ongoing or recurrent seizures in alcohol withdrawal, ensuring immediate safety. Requesting clonazepam (A) requires a physician order and is secondary, IV pump setup (B) is not urgent unless medication is ordered, and ABG (C) is unnecessary unless respiratory distress is present.
The nurse in charge of the labor and delivery department is making the client assignments for the day. Which client should the most experienced nurse receive?
- A. A 40-week pregnant client attached to the fetal monitor having late decelerations.
- B. A 39-week pregnant client in labor with contractions 3 minutes apart.
- C. A 33-week pregnant client with triplets who is on bed rest.
- D. A 26-week pregnant client who is having Braxton Hicks contractions.
Correct Answer: A
Rationale: Late decelerations at 40 weeks (A) indicate fetal distress, requiring the most experienced nurse for close monitoring and potential intervention. Active labor (B), preterm triplets (C), and Braxton Hicks (D) are less critical or stable, suitable for less experienced staff.
A nurse is caring for a client who speaks a language different from the healthcare team. Which action by the nurse best ensures effective communication with the client?
- A. Using family members as interpreters.
- B. Utilizing a professional interpreter provided by the healthcare facility.
- C. Attempting to communicate using basic words and gestures.
- D. Referring the client to a language class for healthcare professionals.
Correct Answer: B
Rationale: A professional interpreter (B) ensures accurate, confidential communication, per Joint Commission standards. Family interpreters (A) risk bias, gestures (C) are unreliable, and language classes (D) are impractical for immediate needs.
A nurse caring for an oncology client notes the client is receiving a vesicant chemotherapy medication via intravenous (IV) infusion. Which assessment finding would warrant immediate action by the nurse?
- A. An inflamed and sore mouth
- B. Nausea and vomiting
- C. Pain and increasing edema at the infusion site
- D. Abdominal pain
Correct Answer: C
Rationale: Pain and edema at the infusion site (C) suggest extravasation of vesicant chemotherapy, a medical emergency requiring immediate cessation and intervention. Sore mouth (A), nausea (B), and abdominal pain (D) are common side effects, not urgent.