Nokea
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.
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Laboratory results
Glucose (fasting)
70–110 mg/dL
(3.9–6.1 mmol/L) 126 mg/dL
(7.0 mmol/L)
The nurse in the outpatient clinic is caring for a 40-year-old client with acromegaly. Which of the following findings would be most important to report to the health care provider?
- A. Dark, leathery skin
- B. Fasting blood glucose level
- C. Presence of S3 and S4 heart sounds
- D. Reports of knee pain when walking
Correct Answer: C
Rationale: S3 and S4 heart sounds indicate heart failure, a serious complication of acromegaly due to cardiac hypertrophy, requiring urgent reporting. Skin changes, glucose levels, and knee pain are expected but less critical.
The nurse is assessing a client who had a thyroidectomy 12 hours ago and is reporting anxiety, tingling around the mouth, and muscle twitching in the hand. Which of the following actions would be a priority for the nurse to take?
- A. Check the area around the incision site for edema
- B. Review the client’s most recent arterial blood gas results
- C. Evaluate the client’s vocal quality and strength
- D. Obtain a blood specimen to check the serum calcium level
Correct Answer: D
Rationale: Anxiety, tingling, and twitching suggest hypocalcemia from parathyroid damage during thyroidectomy, requiring urgent calcium level assessment. Edema, blood gases, and vocal quality are less urgent.
The nurse explains an autograft to a client scheduled for excision of a skin tumor. The nurse knows the client understands the procedure when the client says, 'I will receive tissue from
- A. a tissue bank.
- B. a pig.
- C. my thigh.
- D. synthetic skin.
Correct Answer: C
Rationale: Autografts are done with tissue transplanted from the client's own skin.
The nurse in the outpatient clinic is talking with a client who was diagnosed with hypertension 6 months ago. The client’s current blood pressure is 170/94 mm Hg. Which of the following questions would be most important for the nurse to ask?
- A. Are you feeling overwhelmed at home or work?
- B. Can you describe your daily eating habits to me?
- C. Do you smoke cigarettes or use tobacco products?
- D. How often do you take your antihypertensive medications?
Correct Answer: D
Rationale: Medication adherence is the most critical factor to assess in uncontrolled hypertension (170/94 mm Hg), as non-compliance is a common cause. Stress, diet, and smoking are secondary.
The nurse is giving home care to an elderly client with angina pectoris and Type 2 diabetes mellitus. Which observation is of most concern and should be reported immediately?
- A. The client reports chest discomfort yesterday while taking a walk.
- B. The nurse observes several brown spots on the client's arms and legs.
- C. The client reports an ingrown toenail that is getting more painful.
- D. The client reports shortness of breath when climbing stairs.
Correct Answer: A
Rationale: Chest discomfort in a client with angina suggests possible cardiac ischemia, requiring immediate reporting to prevent myocardial infarction. Brown spots, toenail pain, or exertional dyspnea are less urgent.