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Following the death of a client, a nursing assistant begins to cry uncontrollably and is unable to provide care for the other assigned clients. The nurse should:
- A. Send the nursing assistant home for the remainder of the day.
- B. Explain to the nursing assistant that she will have to learn to cope with loss.
- C. Send the nursing assistant to the lounge and care for the clients herself.
- D. Encourage the nursing assistant to express her feelings about dying.
Correct Answer: D
Rationale: Encouraging the nursing assistant to express feelings supports emotional processing and professional growth. Sending her home or to the lounge avoids the issue. Coping lectures are dismissive.
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A nurse's neighbor complains of severe right flank pain. She explains that it began during the night, but she was able to take acetaminophen (Tylenol) and return to bed. When she awoke, the pain increased in intensity. How should the nurse intervene?
- A. Explain that she can't give medical advice
- B. Inform the neighbor that she might require surgery
- C. Advise the neighbor to seek medical attention
- D. Tell the neighbor that she'll be fine because she was able to get through the night
Correct Answer: C
Rationale: The nurse should advise the neighbor to seek medical attention. Explaining that she can't give medical advice might cause a delay in treatment. It's beyond the nurse's scope of practice to suggest that the neighbor might need surgery. Telling the neighbor she'll be fine might also delay treatment, and it isn't a professional response.
A postoperative client is to be discharged today. She will need to change her dressing daily. Which statement she makes indicates that she understands the process?
- A. I will wash my hands before and after I change the dressing.'
- B. I can touch the dressings with my hands if I only touch the edges.'
- C. I should clean the area around the incision by moving the swab toward it.'
- D. I can put the old dressings directly in the waste basket.'
Correct Answer: A
Rationale: Hand washing before and after dressing changes prevents infection, reflecting proper understanding. Touching dressings, cleaning toward the incision, or improper disposal increase infection risk.
A client states, 'I eat a well-balanced diet. I do not smoke. I exercise regularly, and I have a yearly checkup with my physician. What else can I do to help prevent cancer?' The nurse should respond with which of the following statements?
- A. Sleep at least 6-8 hours a night.
- B. Practice monthly self-breast examination.
- C. Reduce stress.
- D. All of the above.
Correct Answer: D
Rationale: All listed actions—adequate sleep, self-breast exams, and stress reduction—contribute to cancer prevention by supporting immune function, early detection, and overall health. Health Promotion and Management
The nurse is performing a baseline assessment of a client's skin integrity. Which of the following is a key assessment parameter?
- A. Family history of pressure ulcers
- B. Presence of existing pressure ulcers
- C. Potential areas of pressure ulcer development
- D. Overall risk of developing pressure ulcers
Correct Answer: D
Rationale: When assessing skin integrity, the overall risk potential for developing pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers as well as potential areas for development of pressure ulcers. Family history isn't important when assessing skin integrity.
In an emergency the rapid adjustments made by the body are associated with the increased activity of the:
In an emergency the rapid adjustments made by the body are associated with the increased activity of the:
- A. Thyroid gland
- B. Adrenal gland
- C. Pituitary gland
- D. Pancreas
Correct Answer: B
Rationale: The adrenal gland releases catecholamines and cortisol for rapid stress response.