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Prior to being transported to the surgery suite, the nurse asks the client whether he has any allergies. The client responds, 'Doesn't anyone communicate with anyone? I have been asked that question over and over!' What is the nurse's best response?
- A. œI'm sorry! I just have to ask that question for the record.'
- B. œIt's an important question and we just have to check.'
- C. œYou will hear it again and again as you go through surgery.'
- D. œThis question is asked for verification and safety with each new phase of treatment.'
Correct Answer: D
Rationale: Explaining that repeated allergy checks are for safety and verification reassures the client while clarifying the purpose of the question. This response addresses the client's frustration and emphasizes the importance of the process.
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The nurse is preparing an educational program on breast cancer for women at an African American community center. What information is important for the nurse to consider for the discussion?
- A. African American women have the lowest rate of breast cancer.
- B. Most African American women are diagnosed early in the disease process.
- C. Breast cancer concerns vary between socioeconomic levels of African American women.
Correct Answer: C
Rationale: Breast cancer incidence and outcomes can vary significantly across socioeconomic levels due to differences in access to healthcare, screening, and education. This is critical for tailoring an effective educational program. African American women do not have the lowest rate of breast cancer, and they are often diagnosed at later stages, not early.
The nurse notices that a client with Parkinson's disease is coughing frequently when eating. Which one of the following interventions should the nurse consider?
- A. Have the client hyperextend the neck when swallowing.
- B. Tell the client to place the chin firmly against the chest when eating.
- C. Thicken all liquids before offering to the client.
- D. Place the client on a clear liquid diet.
Correct Answer: C
Rationale: Thickening liquids reduces aspiration risk in Parkinson's patients with dysphagia, as coughing indicates swallowing difficulty. Hyperextending the neck or a clear liquid diet increases aspiration risk, and chin tuck is less universally effective.
Which of the following is an assessment finding associated with internal bleeding with disseminated intravascular coagulation?
- A. Bradycardia.
- B. Hypertension.
- C. Increasing abdominal girth.
- D. Petechiae.
Correct Answer: C
Rationale: Internal bleeding in DIC can cause blood accumulation in the abdominal cavity, leading to increasing abdominal girth. Bradycardia and hypertension are not typical, and petechiae are associated with cutaneous bleeding.
The nurse should teach the client with Addison's disease that the adverse effect of bronze-colored skin is thought to be caused by which of the following?
- A. Hypersensitivity to sun exposure.
- B. Increased serum bilirubin level.
- C. Adverse effects of the glucocorticoid therapy.
- D. Increased secretion of adrenocorticotropic hormone (ACTH).
Correct Answer: D
Rationale: Bronze-colored skin in Addison's disease results from increased ACTH, which stimulates melanin production.
An awake postoperative client received an intravenous regional nerve block (Bier block) in the arm that is now casted and elevated on a pillow. What action should the nurse encourage the client to avoid until sensation returns?
- A. Holding the operated arm close to the face.
- B. Holding the operated arm with the unoperated arm.
- C. Using the unoperated arm.
- D. Using pain medication.
Correct Answer: A
Rationale: Without sensation, holding the arm close to the face risks injury, as the client may not feel pressure or positioning issues. The other actions are safe or unrelated.