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Following visitation, the nurse observes a client's wife sitting alone crying. When approached, the wife states, 'I'm so worried about him.' The best response by the nurse is:
- A. Are you worried about him being in the hospital?'
- B. Tell me what is worrying you.'
- C. Would you like to talk with the social worker assigned to your husband?'
- D. Would you like to talk with your husband's doctor?'
Correct Answer: B
Rationale: Tell me what is worrying you' encourages the wife to express her concerns, facilitating support. Other responses assume causes or defer to others prematurely.
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The nurse is reinforcing teaching for a client with hyperlipidemia who has a new prescription for simvastatin. The nurse should instruct the client to take simvastatin
- A. at noon immediately following a meal
- B. in the morning on an empty stomach
- C. at bedtime without regard to food
- D. in the afternoon with a snack
Correct Answer: C
Rationale: Simvastatin is most effective at bedtime, when cholesterol synthesis peaks, and can be taken with or without food. Morning or afternoon dosing reduces efficacy.
The nurse in the mental health unit observes a client hitting the wall repeatedly with the hands after an upsetting family therapy session. The nurse should recognize that the client is exhibiting which of the following defense mechanisms?
- A. projection
- B. displacement
- C. rationalization
- D. reaction formation
Correct Answer: B
Rationale: Defense mechanisms are unconscious mental processes used to protect individuals from uncomfortable thoughts, internal conflicts, and external stresses. Defense mechanisms may be therapeutic to clients with anxiety. However, with excessive use, defense mechanisms may become notherapeutic because they involve a degree of self-deception and reality distortion that can result in poor interpersonal relationships, irrational behavior, and decreased productivity.
The nurse is reinforcing information for a client with chronic obstructive pulmonary disease. Which statements by the client indicate an understanding of the pursed-lip breathing technique? Select all that apply.
- A. I exhale for 2 seconds through pursed lips
- B. I exhale for 4 seconds through pursed lips
- C. I inhale for 2 seconds through my mouth
- D. I inhale for 2 seconds through my nose, keeping my mouth closed
- E. I inhale for 4 seconds through my nose, keeping my mouth closed
Correct Answer: B,D
Rationale: Pursed-lip breathing involves inhaling 2 seconds through the nose (mouth closed) and exhaling 4 seconds through pursed lips to prolong exhalation and reduce air trapping in COPD.
A client is admitted with a head injury. Which vital sign assessment is most indicative of increased intracranial pressure?
- A. BP 120/80, pulse 120, respirations 20
- B. BP 180/98, pulse 50, temperature 102°F
- C. BP 98/60, pulse 132, temperature 97.6°F
- D. BP 170/90, pulse 80, respirations 24
Correct Answer: B
Rationale: Vital signs correlating with increased intracranial pressure are an elevated BP with a widening pulse pressure, a slow pulse rate, and an elevated temperature with involvement of the hypothalamus. Answer C relates to hypovolemia, so it is incorrect. Answers A and D do not relate to increased intracranial pressure and are therefore incorrect.
Which are appropriate examples of cost-effective care? Select all that apply.
- A. Considering the inside of the sterile glove wrapper as a small sterile field
- B. Donning clean, rather than sterile, gloves to remove a client’s dressing
- C. Returning opened, unused supplies from a client’s room to the central supply room
- D. Reusing a tourniquet for multiple clients unless it is visibly soiled
- E. Using remaining sterile saline in a bottle opened 48 hours ago before discarding
Correct Answer: A,B
Rationale: Using the glove wrapper as a sterile field and clean gloves for dressing removal reduce waste without compromising safety. Returning supplies, reusing tourniquets, and using old saline risk contamination or infection.