Nokea
In assessing a post partum client, the nurse palpates a firm fundus and observes a constant trickle of bright red blood from the vagina. What is the most likely cause of these findings?
- A. Uterine atony
- B. Genital lacerations
- C. Retained placenta
- D. Clotting disorder
Correct Answer: B
Rationale: Genital lacerations. Continuous bleeding in the absence of a boggy fundus indicates undetected genital tract lacerations.
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The nurse is making a home visit to an adult who had a cataract extraction yesterday. Which observation indicates that the client needs more instruction?
- A. The client demonstrates putting eye drops in the conjunctival sac.
- B. The client has a patch on the affected eye.
- C. The client bends over to pick up the cat.
- D. The client is wearing slip-on shoes.
Correct Answer: C
Rationale: Bending over post-cataract surgery increases intraocular pressure, risking complications; this indicates a need for further instruction on activity restrictions.
The nurse is caring for a client with schizophrenia who is experiencing visual hallucinations. The client states, 'There is a bad person standing in my room.' Which of the following responses would be most appropriate for the nurse to make?
- A. Your illness is making you experience visual hallucinations.'
- B. I know you are frightened, but I do not see anyone in your room.'
- C. Do not worry. I will give you medication that will make the bad person go away.'
- D. We will go into the dayroom and play a game. I know you like to play board games.'
Correct Answer: B
Rationale: When addressing hallucinations, the nurse should acknowledge the client’s fear while gently reinforcing reality. Response B validates the client’s emotions and clarifies that the nurse does not see the hallucination, maintaining trust without reinforcing the delusion. Labeling the hallucination as part of the illness (A) may confuse or alienate the client. Promising medication will resolve it (C) oversimplifies treatment, and distracting with games (D) dismisses the client’s distress.
The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended?
- A. Seizures
- B. Withdrawal
- C. Craving
- D. Marked tolerance
Correct Answer: B
Rationale: Withdrawal. Early withdrawal symptoms, including nausea and tremor, appear within hours of reducing alcohol intake.
An 8-year-old hospitalized due to a bowel obstruction is to be discharged home with a temporary colostomy. The parents’ primary language is Vietnamese, and their English proficiency is very limited. What is the best approach for the nurse to use when reinforcing instructions to the parents on how to care for the child at home?
- A. Demonstrate the procedure using simple English phrases
- B. Give the parents written instructions with picture illustrations
- C. Tell the parents to have a friend or relative come in to translate
- D. Use an interpreter via the telephone interpretation service
Correct Answer: D
Rationale: A professional interpreter (D) ensures accurate communication, critical for colostomy care. Simple English (A) risks misunderstanding, pictures (B) are insufficient alone, and informal translators (C) may lack medical accuracy.
The nurse is caring for a client with cholelithiasis and acute cholecystitis. The client suddenly vomits 250 mL of greenish-yellow emesis and reports severe right upper quadrant pain with radiation to the right shoulder. Which intervention would have the highest priority?
- A. Administer promethazine suppository
- B. Initiate NPO status
- C. Insert nasogastric tube set to low suction
- D. Obtain prescription for pain medication
Correct Answer: B
Rationale: Acute cholecystitis with vomiting and severe pain suggests gallbladder inflammation or obstruction, requiring immediate cessation of oral intake (NPO status, B) to prevent further stimulation and complications like perforation. Promethazine (A) and pain medication (D) are supportive but secondary. A nasogastric tube (C) may be considered later but is not the priority.