Nokea
Ten-year-old Jackie is admitted to the hospital with a medical diagnosis of Rheumatic Fever. She relates a history of 'a sore throat about a month ago.' Bed rest with bathroom privileges is prescribed. Which of the following nursing assessments should be given the highest priority when assessing Jackie's condition?
- A. her response to being hospitalized
- B. the presence of a macular rash on her trunk
- C. her cardiac status
- D. the presence of polyarthritis and pain in her joints
Correct Answer: C
Rationale: Monitoring cardiac status is of the highest priority. Permanent cardiac damage can result from rheumatic fever. The second priority is assessing the client's joints for the presence of polyarthritis and accompanying pain.
You may also like to solve these questions
The nurse is assessing an elder who the nurse suspects is being physically abused. The most important question for nurse to ask is:
- A. How much money do you keep around the house?
- B. Who provides your physical care?
- C. How close does your nearest relative live?
- D. What form of transportation do you use?
Correct Answer: B
Rationale: The most common abuser is a caregiver living with the client. Research reveals that the spouse is currently the most common abuser, followed by an adult child.
A client goes to the mental health center for difficulty concentrating, insomnia, and nightmares. The client reports being raped as a child. The nurse should assess the client for further signs of:
- A. General anxiety disorder
- B. Schizophrenia
- C. Post-traumatic stress disorder
- D. Bipolar disorder
Correct Answer: C
Rationale: Childhood sexual abuse is strongly associated with post-traumatic stress disorder (PTSD), characterized by nightmares, insomnia, and concentration difficulties.
Support-system enhancement includes all of the following except:
- A. determining the barriers to using support systems.
- B. discussing ways to help with others who are concerned.
- C. exploring life problems of the support-team members.
- D. involving spouse, family, and friends in the care and planning.
Correct Answer: C
Rationale: The exploration of life problems of support-team members is not necessary to enhance the support system. Choices 1, 2, and 4 are all enhancements for a support system.
A nurse gave medications to the wrong client. She stated the client responded to the name called. What is the nurse's appropriate documentation?
- A. Note in medication records the drug given
- B. The client was not hurt, no need for documentation
- C. Note the client's orientation
- D. Completely fill out an incident report
Correct Answer: D
Rationale: The incident report should always be filled out involving medication errors.
A 60-year-old widower is hospitalized after complaining of difficulty sleeping, extreme apprehension, shortness of breath, and a sense of impending doom. What is the best response by the nurse?
- A. You have nothing to worry about. You are in a safe place. Try to relax.'
- B. Has anything happened recently or in the past that might have triggered these feelings?'
- C. We have given you a medication that helps to decrease feelings of anxiety.'
- D. Take some deep breaths and try to calm down.'
Correct Answer: B
Rationale: Choice 2 provides support, reassurance, and an opportunity to gain insight into the cause of the anxiety. Choice 1 dismisses the client's feelings and offers false reassurance. Choices 3 and 4 do not allow the client to discuss his feelings, which he must do in order to understand and resolve the cause of his anxiety.