Nokea
An involuntary psychiatric patient asks the nurse to mail his letter to the President. He states that the letter will make the President regret his actions to prevent homosexuals from serving in the military. Which of the following responses by the nurse is BEST?
- A. Accept the letter and place it in the patient's medical record.
- B. Read the patient's letter and decide if it is appropriate to mail.
- C. Call the patient's psychiatrist and inform him of the letter.
- D. Discourage the patient from sending the letter, but mail it if patient insists.
Correct Answer: D
Rationale: Mailing the letter respects the patient’s communication rights while addressing potential concerns. Options A, B, and C violate autonomy or privacy.
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An adult has been diagnosed with gout. Which comment by the client indicates to the nurse that the client understands management of the condition?
- A. It has been hard to give up chicken and liver.'
- B. I have shrimp two or three times a week.'
- C. My favorite snack is nuts.'
- D. I have oatmeal every day for breakfast.'
Correct Answer: D
Rationale: Oatmeal is low-purine, suitable for gout management, unlike chicken, liver, or shrimp, which are high-purine and increase uric acid. Nuts are moderate and less ideal.
A 24-year-old woman who is 30 weeks pregnant is seen in the outpatient clinic for a routine visit.
The nurse would be MOST concerned if the client made which of the following statements?
- A. During the day I seem to get hot flashes and chills.
- B. I am having some trouble with constipation and hemorrhoids.
- C. At the end of the day I have leg cramps.
- D. When I put my hand on my abdomen, I can feel it tense and relax.
Correct Answer: A
Rationale: Strategy: 'MOST concerned' indicates a complication. (1) correct-should be reported to the physician (2) common due to pressure of growing fetus (3) common due to compression of nerves supplying lower extremities or reduced calcium levels, should take oral calcium supplements if ordered, stretch until spasm is relieved (4) Braxton-Hicks contractions common, should rest and change position
An adult had exploratory surgery and postoperatively had an exacerbation of asthma. The client is on a rebreathing mask and seems upset and angry. What is the best nursing approach?
- A. Ask the physician for an order for lorazepam (Ativan).
- B. Spend some time with the client.
- C. Ask the family to have someone stay with the client.
- D. Apply wrist restraints.
Correct Answer: B
Rationale: Spending time with the client addresses emotional distress, calming them without medication or restraints, supporting asthma management.
The nurse plans care for a 36-year-old woman with Graves' disease. The nurse knows that which of the following foods or fluids should be restricted for this client?
- A. Milk.
- B. Apples.
- C. Orange juice.
- D. Tea.
Correct Answer: D
Rationale: Tea contains caffeine, which can exacerbate hyperthyroidism symptoms like tachycardia in Graves’ disease. Options A, B, and C are not contraindicated.
The preoperative client is from a different country and tells the nurse that his family will be coming for a prayer service. Eighteen persons arrive and start chanting in the client's semiprivate room. What is the best response for the nurse?
- A. Explain that visitors are limited to two per client
- B. Ask the client's roommate if he/she objects to so many persons in the room
- C. Ignore the large number of people and the chanting
- D. Arrange for the group to go to the conference room or the chapel
Correct Answer: D
Rationale: Arranging for a private space respects cultural practices while minimizing disruption to the roommate, balancing sensitivity and practicality.