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On entering a toddler's room, the nurse finds the mother sitting about 8 feet from the child and watching television while the toddler is screaming. Which of the following is the most appropriate response by the nurse?
- A. What happened between you and your child?'
- B. Why is your child screaming?'
- C. Did something cause your child to be upset?'
- D. Have you tried to calm down your child?'
Correct Answer: C
Rationale: This response seeks to understand the situation without judgment, encouraging the mother to explain the toddler's distress.
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The nurse is teaching a client with a new diagnosis of epilepsy about driving restrictions. Which of the following instructions is most appropriate?
- A. You can drive after being seizure-free for 6 months.
- B. You can drive if you take your medication regularly.
- C. You can drive with a passenger at all times.
- D. You can drive during the daytime only.
Correct Answer: A
Rationale: Most regions require a client to be seizure-free for 6 months before driving, ensuring safety.
During the admission interview, an adult client reveals that, as a child, she was sexually abused by her uncle and a male cousin. She reports that she cuts the skin of her arms, legs, and abdomen. In addition to having the client sign a no-harm contract, which nursing intervention is most important?
- A. Assist the client with finding safe ways to express her anger.
- B. Talk with the client about confronting her uncle and cousin directly.
- C. Defer talking about the abuse to prevent further self-mutilation.
- D. Discuss the possibility of the client suing her relatives for their abuse.
Correct Answer: A
Rationale: Helping the client find safe ways to express anger addresses the self-harm behavior therapeutically, promoting coping skills and safety.
The nurse is teaching a client about the use of a transdermal nicotine patch for smoking cessation. Which instruction is correct?
- A. Apply it to the same site daily
- B. Remove it at night
- C. Keep it on during showers
- D. Apply it to the face
Correct Answer: B
Rationale: Removing the nicotine patch at night reduces the risk of side effects like insomnia and allows a nicotine-free period.
Methylergonovine maleate is prescribed for a woman who has just delivered a healthy newborn. Which is the priority assessment to complete before administering the medication?
- A. Lochia
- B. Uterine tone
- C. Blood pressure
- D. Deep tendon reflexes
Correct Answer: C
Rationale: Methylergonovine maleate, an oxytocic, is an agent used to prevent or control postpartum hemorrhage by contracting the uterus. The immediate dose is administered intramuscularly, and then, if still needed, it is administered orally. It causes uterine contractions and may elevate the blood pressure. A priority assessment before administration of methylergonovine maleate is blood pressure. Methylergonovine maleate is to be administered cautiously in the presence of hypertension, and the primary health care provider should be notified if hypertension is present. Options 1 and 2 are general components of care in the postpartum period. Option 4 is most specifically related to the administration of magnesium sulfate.
Clients who are receiving total parenteral nutrition (TPN) are at risk for development of which of the following complications?
- A. Hypostatic pneumonia.
- B. Pulmonary hypertension.
- C. Orthostatic hypotension.
- D. Fluid imbalances.
Correct Answer: D
Rationale: TPN can cause fluid imbalances due to high glucose and volume loads, requiring close monitoring of intake, output, and electrolytes.