Nokea
During administration of oral medications to an elderly, confused client, the client states, 'These pills look funny. They belong to the lady down the hall.' Which of the following is the BEST response by the nurse?
- A. Your physician has ordered new medications for you. They will help you get well.
- B. Remember yesterday when I brought your medications? They look the same.
- C. I'll explain why you are receiving these medications.
- D. I'll be back after I check your medications again.
Correct Answer: D
Rationale: Rechecking medications ensures safety, addressing the client’s concern about a possible error. Options A, B, and C risk administering incorrect drugs.
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A 53-year-old who has pernicious anemia is being seen in the physician's office. Because the client has pernicious anemia, which comment is of greatest concern to the nurse?
- A. I have been having trouble reading the newspaper.'
- B. I have pain up and down my legs.'
- C. My knees hurt when I climb stairs.'
- D. I am so tired of having a headache.'
Correct Answer: B
Rationale: Leg pain suggests worsening neuropathy, a serious complication of pernicious anemia, requiring urgent evaluation to prevent irreversible nerve damage.
A ten-year-old child with leukemia has a large burn on her arm and the burn appears to be oily. The client states that she touched a hot pan, and her mother put cooking fat on it so it would not blister.
The nurse should
- A. document the findings in the chart.
- B. call the physician immediately to report the injury.
- C. teach the client that oil holds germs and makes infection more likely.
- D. wash the burn with soap and water to remove the oil.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the immediate problem of cleansing the wound (2) unnecessary (3) does not address the immediate problem of cleansing the wound (4) correct-because leukemic clients are immunosuppressed, they are more susceptible to infections; cooking fat applied to an open wound increases the possibility of infection; burns should be rinsed immediately with tap water to reduce the heat in the burn
An 18-year-old client with anorexia nervosa is admitted to the hospital.
In planning to care for the client, the nurse would expect the client to
- A. view her appearance as 'skinny.'
- B. be hypoactive and withdrawn.
- C. want to talk about and plan her meals.
- D. have a close relationship with her mother.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to anorexia. (1) usually view their appearance as fat (2) inaccurate for client with anorexia nervosa (3) correct-display a marked preoccupation with food (4) inaccurate for client with anorexia nervosa
An adult client became incontinent while hospitalized. The client now drinks very little. The nurse understands that this is:
- A. a coping strategy.
- B. a defense mechanism.
- C. a way to not bother the nurse.
- D. regression.
Correct Answer: A
Rationale: Reduced fluid intake is a coping strategy to avoid incontinence, though it risks dehydration, reflecting an attempt to manage embarrassment.
The nurse is participating in a community health fair. As part of the assessments, the nurse should conduct a mental status examination when
- A. An individual displays restlessness
- B. There are obvious signs of depression
- C. Conducting any health assessment
- D. The resident reports memory lapses
Correct Answer: C
Rationale: Conducting any health assessment. A mental status examination is a critical part of baseline health assessments.