Nokea
If the client's drug screen is positive for cocaine, it is most appropriate for the nurse to advise a staff person to monitor the client closely for which finding?
- A. Cardiac arrhythmias
- B. Depressed respirations
- C. Low heart rate
- D. Elevated blood glucose level
Correct Answer: A
Rationale: Cocaine's stimulant effects increase the risk of cardiac arrhythmias, a potentially life-threatening complication requiring close monitoring.
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The nurse is caring for the client who was violently raped 3 months ago and has a diagnosis of rape-trauma syndrome. Which assessment findings associated with rape-trauma syndrome should the nurse anticipate? Select all that apply.
- A. Anorexia
- B. Nightmares
- C. Hypertension
- D. Fears and phobias
- E. Sexual promiscuity
Correct Answer: A ,B, D
Rationale: Rape-trauma syndrome symptoms include physiological symptoms such as loss of appetite (A) nightmares of the attack occurring again (B) and fears and phobias (D) due to feelings of vulnerability. Hypertension (C) is not a recognized symptom and fear of sexual encounters not promiscuity (E) is typical.
The client is receiving clonidine to relieve selected symptoms of opioid withdrawal. Which assessment is most important for the nurse to complete before administering clonidine?
- A. Check for presence of dilated pupils
- B. Investigate recent nausea or vomiting
- C. Test for abnormally heightened reflexes
- D. Verify that the blood pressure is not low
Correct Answer: D
Rationale: Clonidine requires BP check (D) to avoid hypotension. Dilated pupils (A) nausea (B) and reflexes (C) don’t contraindicate it.
If the older adult's sons and daughters are visiting on the day of the scheduled nurse's visit, which action is most appropriate before beginning the assessment?
- A. Encourage the client's children to offer their comments at any time.
- B. Provide a private setting for conducting the assessment.
- C. Identify the names and relationships of those present.
- D. Offer to share the assessment results with the client's children.
Correct Answer: B
Rationale: A private setting ensures confidentiality and encourages honest responses, critical for an accurate health assessment.
Which form of instruction is most beneficial when preparing the anxious client?
- A. Provide detailed explanations.
- B. Use short, simple sentences.
- C. Draw elaborate diagrams.
- D. Show a teaching DVD.
Correct Answer: B
Rationale: Short, simple sentences are easier for an anxious client to process, reducing cognitive overload and improving comprehension.
If the client frequently comes to meals with the residue of soap on the face or an unbuttoned shirt, which action by the nurse is most beneficial to the client's emotional state?
- A. Send the client back to finish.
- B. Bathe and dress the client daily.
- C. Schedule the client's hygiene activities after meals.
- D. Comment on how self-reliant the client is.
Correct Answer: C
Rationale: Scheduling hygiene after meals allows assistance without embarrassment, supporting the client's dignity and emotional well-being.