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Several days before admission, a client reports finding a small lump in the left breast near the nipple. What should the nurse tell the client to do?
- A. Inform the physician immediately
- B. Squeeze the nipple to check for drainage
- C. Check the area after the next menstrual period
- D. Put a heating pad on the area to reduce inflammation
Correct Answer: A
Rationale: The correct answer is A: Inform the physician immediately. This is because finding a lump in the breast could be a sign of breast cancer, and early detection is crucial for effective treatment. The nurse should advise the client to seek medical evaluation promptly for further assessment, such as a mammogram or biopsy.
Choice B is incorrect because squeezing the nipple could potentially worsen the condition or spread cancerous cells if present. Choice C is incorrect as waiting until after the next menstrual period may delay necessary medical attention. Choice D is incorrect as using a heating pad could mask symptoms and delay proper diagnosis and treatment.
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A nurse has instituted a turn schedule for a patient to prevent skin breakdown. Upon evaluation, the nurse finds that the patient has a stage II pressure ulcer on the buttocks. Which action will the nurse take next?
- A. Reassess the patient and situation.
- B. Revise the turning schedule to increase the frequency.
- C. Delegate turning to the nursing assistive personnel.
- D. Apply medication to the area of skin that is broken down.
Correct Answer: A
Rationale: The correct answer is A: Reassess the patient and situation. The nurse should reassess to determine the cause of the pressure ulcer, evaluate the effectiveness of the current turning schedule, and identify any contributing factors. This allows for a more targeted intervention plan.
B: Incorrect. Simply increasing the frequency of turning may not address the underlying issue causing the pressure ulcer.
C: Incorrect. Delegating turning to nursing assistive personnel without reassessment may not address the root cause of the pressure ulcer.
D: Incorrect. Applying medication without reassessment may not address the underlying cause of the pressure ulcer and could potentially worsen the condition.
A client with acquired immunodeficiency syndrome (AIDS) is admitted with Pneumocystis carinii pneumonia. During a bath, the client begins to cry and says that most friends and relatives have stopped visiting and calling. What should the nurse do?
- A. Continue with the bath and tell the client not to worry
- B. Ask the physician to obtain a psychiatric consultation
- C. Listen and show interest as the client expresses feelings
- D. State that these friends’s behavior shows that they aren’t true friends
Correct Answer: C
Rationale: The correct answer is C: Listen and show interest as the client expresses feelings. It is essential for the nurse to actively listen and show empathy towards the client's emotional distress. This approach demonstrates compassion, understanding, and support for the client during a vulnerable moment, which is crucial for the therapeutic relationship. By actively listening, the nurse can validate the client's emotions and provide a safe space for them to express their feelings. This can help the client feel heard and supported, leading to improved emotional well-being.
Choices A, B, and D are incorrect:
A: Continuing with the bath and telling the client not to worry dismisses the client's emotions and fails to address their underlying feelings of loneliness and isolation.
B: Asking for a psychiatric consultation may not be necessary at this point, as the client's emotional distress can be effectively managed through therapeutic communication.
D: Stating that the friends' behavior shows they aren't true friends is judgmental and unhelpful, as it does not address
The nurse performs an intervention for a collaborative problem. Which type of intervention did the nurse perform?
- A. Dependent NursingStoreRN
- B. Independent
- C. Interdependent
- D. Physician-initiated
Correct Answer: C
Rationale: The correct answer is C: Interdependent. In this scenario, the nurse performed an intervention for a collaborative problem, which involves working together with other healthcare professionals to address the issue. Interdependent interventions require collaboration and communication among healthcare team members to achieve the best outcomes for the patient.
Choice A (Dependent Nursing) refers to interventions that require an order from a healthcare provider.
Choice B (Independent) involves nursing actions that the nurse can initiate without the need for a healthcare provider's order.
Choice D (Physician-initiated) specifically denotes interventions initiated by a physician without direct involvement from the nurse.
In this case, the nurse's intervention for a collaborative problem aligns with the definition of interdependent intervention, making it the correct choice.
While the patient’s lower extremity, which is in a cast, is assessed, the patient tells the nurse about an inability to rest at night. The nurse disregards this information, thinking that no correlation has been noted between having a leg cast and developing restless sleep. Which action would have been best for the nurse to take?
- A. Tell the patient to just focus on the leg and cast right now.
- B. Document the sleep patterns and information in the patient’s chart.
- C. Explain that a more thorough assessment will be needed next shift.
- D. Ask the patient about usual sleep patterns and the onset of having difficulty resting.
Correct Answer: D
Rationale: The correct answer is D because it involves a comprehensive approach to addressing the patient's concern. By asking the patient about usual sleep patterns and the onset of having difficulty resting, the nurse can gather important information to assess the potential correlation between the leg cast and restless sleep. This approach demonstrates active listening and shows concern for the patient's well-being.
Option A is incorrect because it dismisses the patient's concern and does not address the underlying issue. Option B is also incorrect as it focuses solely on documentation without actively addressing the patient's concern. Option C is not the best choice as it delays addressing the patient's immediate need for help with sleeping, which may impact their overall recovery.
Which of the following is the medication of choice for anaphylaxis that the nurse should anticipate would be ordered?
- A. Epinephrine
- B. Digoxin (Lanoxin)
- C. Theophylline (Theo-Dur)
- D. Furosemide (Lasix)
Correct Answer: A
Rationale: The correct answer is A: Epinephrine. In anaphylaxis, epinephrine is the medication of choice due to its rapid onset of action and ability to reverse severe allergic reactions. It acts by constricting blood vessels, increasing heart rate, and opening airways. This helps counteract the dangerous drop in blood pressure and airway constriction seen in anaphylaxis. Digoxin, theophylline, and furosemide are not appropriate for anaphylaxis as they do not address the immediate life-threatening symptoms of anaphylaxis.