Nokea
In attempting to develop a therapeutic relationship with a male adult client transferred to a psychiatric facility after being treated for a self-inflicted gunshot wound, which information is most important for the nurse to determine?
- A. The family's reaction to this situation
- B. The nurse's feelings about this client
- C. What losses the client recently experienced
- D. Why the client attempted to kill himself
Correct Answer: C
Rationale: Understanding what losses the client recently experienced is crucial for the nurse in developing a therapeutic relationship. This information helps the nurse comprehend the client's emotional state, the potential triggers for the self-harm behavior, and provides insights into the client's current psychological and social challenges. Choice A, the family's reaction, may be important but is secondary to understanding the client's own experiences. Choice B, the nurse's feelings, is not relevant as the focus should be on the client. Choice D, why the client attempted suicide, is important but delving into recent losses can provide a broader context for the client's emotional distress and suicidal behavior.
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A client in the oliguric phase of acute renal failure (ARF) has a 24-hour urine output of 400 ml. How much oral intake should the nurse allow this client to have during the next 24 hours?
- A. Encourage oral fluids as tolerated
- B. Decrease oral intake to 200 ml
- C. Allow the client to have exactly 400 ml oral intake
- D. Limit oral intake to 900 to 1,000 ml
Correct Answer: D
Rationale: In the oliguric phase of acute renal failure (ARF), the goal is to prevent fluid overload. Since the client has a low urine output of 400 ml in 24 hours, limiting oral intake to 900 to 1,000 ml is appropriate. Encouraging unrestricted oral fluids (Choice A) can exacerbate fluid overload. Decreasing oral intake to 200 ml (Choice B) would be too restrictive and may lead to dehydration. Allowing the client to have exactly 400 ml oral intake (Choice C) would not account for other sources of fluid intake and output, potentially resulting in fluid imbalance.
At a community health fair, a 50-year-old woman tells the nurse that she has an annual physical exam that includes a clinical breast exam and an annual mammogram. How should the nurse respond?
- A. Encourage the woman to explore her fears about breast cancer.
- B. Ask the woman if she also performs monthly breast self-exams.
- C. Commend the woman for adhering to the recommended cancer detection guidelines.
- D. Advise the woman that mammograms are only needed every two years at her age.
Correct Answer: B
Rationale: The correct answer is B. Monthly breast self-exams are essential for early detection of breast cancer. While annual clinical breast exams and mammograms are important, monthly self-exams enhance early detection by helping women become familiar with their breasts and notice any changes. Choice A is incorrect as it does not address the importance of self-exams. Choice C is incorrect as it prematurely commends without ensuring the woman is conducting self-exams. Choice D is incorrect as it provides inaccurate information about the frequency of mammograms needed.
The nurse enters the room of a client with a nasogastric tube who is receiving continuous feeding. The nurse observes that the client is coughing and that the infusion pump is alarming. What action should the nurse take first?
- A. Auscultate the client's breath sounds
- B. Turn the client to the side
- C. Stop the feeding infusion
- D. Notify the healthcare provider
Correct Answer: C
Rationale: The correct action for the nurse to take first in this situation is to stop the feeding infusion. Coughing in a client with a nasogastric tube can indicate aspiration, which can be a serious complication. By stopping the feeding infusion immediately, the nurse can prevent further aspiration and related complications. Auscultating breath sounds or turning the client to the side may be necessary actions but addressing the feeding infusion is the priority. Notifying the healthcare provider can be done after the immediate issue of potential aspiration is managed.
The nurse in a community health clinic is interviewing a female client who has three children. The client tells the nurse that she has a new man in her life, with whom she is having a sexual relationship, and that they both smoke cigarettes. Which information is most important for the nurse to provide this client?
- A. Oral contraceptives should be started to prevent an unwanted pregnancy
- B. Children are more prone to upper respiratory infections if exposed to smoke at home
- C. Cigarette smoking increases the risk for peptic ulcers and emphysema
- D. A diaphragm and condom provide effective contraception when used together
Correct Answer: D
Rationale: The most important information for the nurse to provide the client in this situation is that using both a diaphragm and a condom together provides effective contraception and also protects against sexually transmitted diseases (STDs). While oral contraceptives can help prevent unwanted pregnancies, using a barrier method like a diaphragm and a condom is crucial in this scenario where the client is engaging in a new sexual relationship. Choice B is important information but is not the top priority in this context. Choice C, although relevant, does not address the immediate concern of contraception and STD prevention. Therefore, the correct answer is D.
A client who is HIV positive and taking lamivudine (Epivir) calls the clinic to report a cough and fever. What action should the nurse implement?
- A. Advise the client to come to the clinic for an evaluation
- B. Advise the client to increase fluid intake
- C. Advise the client to take an over-the-counter cough suppressant
- D. Advise the client to rest and call if the fever persists
Correct Answer: A
Rationale: The correct action for the nurse to implement in this situation is to advise the client to come to the clinic for an evaluation. Given the client's HIV-positive status and medication, it is crucial to assess the cough and fever promptly to identify the underlying cause. Increasing fluid intake (choice B) may be beneficial but does not address the need for evaluation. Taking an over-the-counter cough suppressant (choice C) may not be appropriate without knowing the cause of the symptoms. Advising the client to rest and call if the fever persists (choice D) delays the necessary evaluation and treatment.