Nokea
One afternoon 3 weeks into his alcohol treatment program, a client says to the nurse, 'It's really not all my fault that I have a drinking problem. Alcoholism runs in my family. Both my grandfather and father were heavy drinkers.' The nurse's best response would be:
- A. That might be a problem. Tell me more about them.'
- B. Risk factors can often be controlled by self-responsibility.'
- C. It sounds like you're intellectualizing your drinking problem.'
- D. Your grandfather and father were both alcoholics?'
Correct Answer: B
Rationale: Focusing is an effective therapeutic strategy. This response, however, allows the client to 'defocus' off the topic of learning how to accept responsibility for his behavior and future growth. The nurse can educate the client about both the 'genetic risk' for the development of alcoholism and ways to make long-term healthy lifestyle changes. This response is inappropriately confrontational and condescending to the client. Reflection of content can be an effective verbal therapeutic technique. It is used inappropriately here.
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A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of 'not feeling well.' At 4:30 PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to:
- A. Give him 3 tbsp of sugar dissolved in 4 oz of grape juice to drink
- B. Ask him to dissolve three pieces of hard candy in his mouth
- C. Have him drink 4 oz of orange juice
- D. Monitor him closely until dinner arrives
Correct Answer: C
Rationale: Four ounces of orange juice will raise blood sugar to a normal level and sustain it until dinner, preventing hypoglycemia. The other options either raise blood sugar too high or are insufficient.
The nurse is assessing the client’s bowel sounds. Which finding indicates normal bowel sounds?
- A. Stronger than normal
- B. Hypoactive
- C. Normal
- D. Hyperactive
Correct Answer: C
Rationale: Normal bowel sounds are described as 'normal,' occurring every 5–20 seconds with a gurgling quality. Stronger than normal or hyperactive sounds suggest increased motility (e.g., diarrhea), while hypoactive sounds indicate reduced motility (e.g., ileus).
A 22-year-old client is 16 weeks pregnant. She and her husband are expecting their first baby. The client tells the nurse that her last normal menstrual period was February 16, with 3 days of spotting on February 17, 18, and 19. The nurse calculates her expected date of delivery to be:
- A. November 23rd
- B. December 26th
- C. September 14th
- D. December 9th
Correct Answer: A
Rationale: Naegele's rule is as follows: add 7 days to the 1st day of the last menstrual period, subtract 3 months, and then add 1 year. Naegele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naegele's rule. Naegele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naegele's rule. Naegele's rule presumes that the woman has a 28-day menstrual cycle, with conception occurring on the 14th day of the cycle. Slight vaginal spotting may occur in early gestation for unknown reasons but is insignificant in the calculation of Naegele's rule.
A client with a fractured femur is placed in skeletal traction. Which assessment finding requires immediate intervention?
- A. The client’s foot is cool to the touch.
- B. The client reports pain at the fracture site.
- C. The traction weights are resting on the floor.
- D. The client is performing active range of motion exercises.
Correct Answer: A
Rationale: A cool foot indicates potential vascular compromise, a serious complication in skeletal traction requiring immediate intervention to prevent tissue damage. Pain is expected, weights on the floor disrupt traction but are less urgent, and exercises are encouraged if appropriate.
At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her contractions are every 5 minutes and last 60 seconds, her cervix is closed, and the suture placed around her cervix during her 16th week of gestation, when she had the MacDonald procedure, can still be felt by the physician. The amniotic sac is still intact. She is very concerned about delivering prematurely. She asks the RN, 'What is the greatest risk to my baby if it is born prematurely?' The RN's answer should be:
- A. Hyperglycemia
- B. Hypoglycemia
- C. Lack of development of the intestines
- D. Lack of development of the lungs
Correct Answer: D
Rationale: Any infant would be at risk for hyperglycemia because the infant's liver is missing the islets of Langerhans, which secrete insulin to break down glucose for cellular use. Prematurity is not an added risk for hyperglycemia. Both premature and mature infants can be at risk for hypoglycemia if their mother had gestational diabetes during pregnancy or entered the pregnancy with diabetes mellitus. These infants are exposed to high levels of maternal glucose while in utero, which causes the islets of Langerhans in the infant's liver to produce insulin. After birth when the umbilical cord is severed, the generous amount of maternal blood glucose is eliminated; however, there is continued islet cell hyperactivity in the infant's liver, which can lead to excessive insulin levels and depleted blood glucose. Mature infants are born with an immature GI system. The nervous control of the stomach is incomplete at birth, salivary glands are immature at birth, and the intestinal tract is sterile. This is not the greatest risk to a premature infant. The greatest risk to a premature infant is the lack of development of the lungs, which can lead to respiratory distress syndrome due to insufficient surfactant production.