Nokea
Describe assessment data for the suicidal client.
- A. Increased alertness
- B. Lower immune response
- C. Faster metabolism
- D. Enhanced digestion
Correct Answer: D
Rationale: The correct answer is D because it is the most appropriate response based on physiological and medical principles.
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A patient with chronic cancer-related pain has started using MS Contin for pain control and has developed common side effects of the drug. The nurse reassures the patient that tolerance will develop to most of these side effects but that continued treatment will most likely be required for what?
- A. Pruritus
- B. Constipation
- C. Dizziness
- D. Nausea and vomiting
Correct Answer: B
Rationale: The correct answer is B. Constipation is a persistent side effect of opioids.
A client just had a flexible bronchoscopy. Which of the following nursing actions is appropriate?
- A. Withhold food and liquids until the client's gag reflex returns.
- B. Irrigate the client's throat every 4 hours.
- C. Have the client refrain from talking for 24 hours.
- D. Suction the client's oropharynx frequently.
Correct Answer: A
Rationale: The correct answer is A: Withhold food and liquids until the client's gag reflex returns. After a flexible bronchoscopy, the client may have a decreased gag reflex due to topical anesthesia used during the procedure, which increases the risk of aspiration. Withholding food and liquids helps prevent aspiration until the gag reflex returns, usually within 1-2 hours.
B: Irrigating the client's throat every 4 hours is unnecessary and may not be indicated post-bronchoscopy.
C: Having the client refrain from talking for 24 hours is not necessary after a flexible bronchoscopy unless specifically instructed by the healthcare provider.
D: Suctioning the client's oropharynx frequently is not indicated unless there is a clinical indication for it, such as excessive secretions or respiratory distress. Frequent suctioning can increase the risk of trauma to the airway.
Which of the following tasks is most appropriate to delegate to the nursing assistant?
- A. Escort the family to a place of privacy
- B. Go with the organ donor specialist to talk to the family
- C. Assist with postmortem care
- D. Assist the family to collect belongings
Correct Answer: C
Rationale: Postmortem care involves basic hygiene and positioning, which can be performed by a nursing assistant.
Karen is suspected of having a hormone imbalance. What would you expect to monitor
- A. Electrolyte levels.
- B. Thyroid studies, follicle-stimulating hormone (FSH), and luteinizing hormone (LH).
- C. Caloric intake.
- D. All of the above.
Correct Answer: D
Rationale: Hormonal imbalances affect multiple systems and require comprehensive monitoring.
Why is it important to acknowledge the 'comfort zone' of a client? How can a nurse relieve a client’s anxiety about physical closeness?
- A. To ensure the client feels respected and safe.
- B. To maintain professional distance.
- C. To facilitate quicker recovery.
- D. To comply with hospital policies.
Correct Answer: A
Rationale: Acknowledging a client's comfort zone respects their personal boundaries, reducing anxiety and promoting a trusting environment.