Nokea
In performing the initial nursing assessment on a client at the prenatal clinic, the nurse will know that which of the following alterations is abnormal during pregnancy?
- A. Striae gravidarum
- B. Chloasma
- C. Dysuria
- D. Colostrum
Correct Answer: C
Rationale: Dysuria is abnormal and may indicate a urinary tract infection, unlike the other options, which are normal pregnancy changes.
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A nurse indicates that she is licensed in her new state of residence even though reciprocity has not been granted. The nurse’s action can result in a charge of:
- A. Fraud
- B. Tort
- C. Malpractice
- D. Negligence
Correct Answer: A
Rationale: Claiming licensure without reciprocity is a deliberate misrepresentation, constituting fraud. A tort is a civil wrong, malpractice involves substandard care, and negligence implies carelessness, none of which fully describe this intentional act.
The nurse is performing discharge teaching to a client who is on isoniazid (INH). Which diet selection by the client indicates to the nurse that further instruction is needed?
- A. Tuna casserole
- B. Ham salad sandwich
- C. Baked potato
- D. Broiled beef roast
Correct Answer: A
Rationale: Isoniazid has MAOI properties, requiring avoidance of tyramine-rich foods like tuna to prevent hypertensive crisis. Tuna casserole (A) indicates a need for further teaching. Ham salad (B) may have tyramine but is less definitive. Baked potato (C) and beef roast (D) are safe.
The nurse is caring for a client with a history of a fractured femur who is in a cast. The client complains of swelling. The nurse should:
- A. Apply ice to the cast
- B. Elevate the leg
- C. Massage the leg
- D. Notify the physician immediately
Correct Answer: B
Rationale: Elevating the leg reduces swelling in a casted femur by improving venous return. Ice is helpful, massage is contraindicated, and notification is needed if swelling persists.
A client with a history of renal failure is admitted with complaints of shortness of breath. The nurse should expect the client to have:
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: Renal failure impairs acid excretion, leading to metabolic acidosis, which can cause compensatory hyperventilation and shortness of breath.
The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in 12 hours if needed. The most likely rationale for this order is:
- A. The client will settle down more quickly if he thinks the staff is medicating him
- B. The medication will sedate the client until the physician arrives
- C. Haloperidol is a minor tranquilizer and will not oversedate the client
- D. Rapid neuroleptization is the most effective approach to care for the violent or potentially violent client
Correct Answer: D
Rationale: If the client could think logically, he would not be paranoid. In fact, he is probably suspicious of the staff, too. Newly admitted clients frequently experience high levels of anxiety, which can contribute to delusions. The goal of pharmacological intervention is to calm the client and assist with reality-based thinking, not to sedate him. Haloperidol is a neuroleptic and antipsychotic drug, not a minor tranquilizer. Haloperidol is a high-potency neuroleptic and first-line choice for rapid neuroleptization, with low potential for sedation.