Nokea
A client who had previously signed the consent for liver biopsy has changed his mind and no longer wants the procedure.
The best initial response by the nurse would be:
- A. Why did you originally sign the consent?
- B. Can you tell me why you decided to refuse the procedure?
- C. You are obviously afraid about something concerning the procedure.
- D. Although the procedure is very important, I understand why you changed your mind.
Correct Answer: B
Rationale: Exploring the reason for refusal respects the patient's autonomy and facilitates informed decision-making.
You may also like to solve these questions
Because the client is thought to have Cushing's syndrome, the nurse should assess the client for the presence of which of the following? Select all that apply.
- A. High blood sugar
- B. Evidence of easy bruising
- C. Low blood pressure
- D. Immunosuppression
- E. Fluid retention
- F. Pitting acne
Correct Answer: A,B,D,E
Rationale: Cushing's syndrome causes hyperglycemia, easy bruising, immunosuppression, and fluid retention due to excess cortisol. Hypertension, not low blood pressure, and acne are common, but pitting is not specific.
An 82-year-old woman who has Alzheimer's disease is admitted to the acute care unit. She frequently gets out of bed and wanders in the hall, unable to find her way back to her room. She even gets in the beds of other clients. What nursing action is most appropriate for this client?
- A. Restrain her so she will not wander in the halls
- B. Ask her roommate to call the nurse whenever she leaves the room
- C. Punish her when she gets in a bed other than her own
- D. Put her favorite picture on the door to her room
Correct Answer: D
Rationale: A familiar picture on the door helps the Alzheimer's client recognize her room, reducing wandering safely. Restraints, roommate monitoring, or punishment are inappropriate or ineffective.
A nurse's neighbor complains of severe right flank pain. She explains that it began during the night, but she was able to take acetaminophen (Tylenol) and return to bed. When she awoke, the pain increased in intensity. How should the nurse intervene?
- A. Explain that she can't give medical advice
- B. Inform the neighbor that she might require surgery
- C. Advise the neighbor to seek medical attention
- D. Tell the neighbor that she'll be fine because she was able to get through the night
Correct Answer: C
Rationale: The nurse should advise the neighbor to seek medical attention. Explaining that she can't give medical advice might cause a delay in treatment. It's beyond the nurse's scope of practice to suggest that the neighbor might need surgery. Telling the neighbor she'll be fine might also delay treatment, and it isn't a professional response.
A client is being admitted with a diagnosis of possible pancreatitis. Which of the following is the best support for this diagnosis?
- A. Pain is in the left upper quadrant of the abdomen
- B. Client reports steatorrhea for the last 3 days
- C. A serum amylase level of 366 U/L
- D. Assessed diminished bowel sounds
Correct Answer: C
Rationale: The client's amylase level is elevated above the normal level of 200 U/L. This measurement is the most accurate indicator of pancreatitis and the most objective and specific. The answers in A, B, and D are also clinical manifestations of pancreatitis, but are not as specific as the laboratory value, so they are incorrect choices.
Which of the following is considered a sequela of a staphylococcal infection that may result to glomerulonephritis?
Infected burn wound
- A. Impetigo
- B. Skin problem from chickenpox
- C. Herpes simplex
Correct Answer: B
Rationale: Impetigo is a bacterial infection of the skin caused by streptococci or staphylococci. Group A hemolytic streptococci can cause rheumatic fever and glomerulonephritis.