Nokea
The client diagnosed with rule-out osteosarcoma asks the nurse, 'Why am I having a bone scan?' Which statement is the nurse’s best response?
- A. You seem anxious. Tell me about your anxieties.'
- B. Why are you concerned? Your HCP ordered it.'
- C. I’ll have the radiologist come back to explain it again.'
- D. A bone scan looks for cancer or infection inside the bones.'
Correct Answer: D
Rationale: A bone scan detects cancer or infection, directly answering the client’s question. Addressing anxiety, deferring to the HCP, or radiologist involvement is less informative.
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Which signs/symptoms indicate to the nurse the client has developed osteoporosis?
- A. The client has lost one (1) inch in height.
- B. The client has lost 12 pounds in the last year.
- C. The client's hands are painful to the touch.
- D. The client's serum uric acid level is elevated.
Correct Answer: A
Rationale: Height loss indicates vertebral compression fractures, a common osteoporosis sign. Weight loss, hand pain, and uric acid elevation are unrelated.
What is true about absence seizures in children?
- A. For most children, absence seizures stop during early teen years.
- B. Absence seizures rarely progress to other seizures.
- C. Teachers often note signs of absence seizures, but seeing them is not adequate for diagnosis.
- D. Absence seizures usually exist in isolation; usually the child has no other neurological condition.
Correct Answer: A
Rationale: Most children outgrow absence seizures during their early teen years.
The nurse assesses the client 6 hours following a lumbar spinal fusion. The client has a throbbing headache, but VS and CMS of the lower extremities are WNL. The lungs have fine basilar crackles. The back dressing has a dime-sized bloody spot surrounded by clear yellow drainage. Which nursing action demonstrates the nurse's best clinical judgment?
- A. Give prescribed morphine sulfate IV
- B. Have the client cough and deep breathe
- C. Reinforce the incisional dressing
- D. Notify the health care provider
Correct Answer: D
Rationale: D. A bloody area surrounded by clear yellowish fluid on the dressing and the client's headache suggest a CSF leak. The nurse should notify the HCP.
Which level of participation should the nurse expect when assessing a 9-year-old who has mental retardation with an IQ level of 45?
- A. Able to communicate verbally only with two-letter words
- B. Able to read and comprehend simple written instructions
- C. Able to walk independently and perform a simple skill
- D. Able to perform tasks that require careful manual dexterity
Correct Answer: C
Rationale: An IQ of 45 indicates moderate intellectual disability, allowing independent walking and simple tasks.
The client is admitted to the hospital for a diagnostic workup. The client has vague symptoms of malaise, coughing, chest discomfort, low-grade fever, diffuse rashes, and musculoskeletal aches and pains. A diagnosis of probable lupus erythematosus has been made. The night nurse finds the client crying and saying, 'I would rather die than suffer with this disease for the rest of my life.' Which response by the nurse would be most therapeutic at this time?
- A. Telling the client there are support groups to join after discharge
- B. Offering to stay with the client to discuss concerns and questions
- C. Advising the client to write concerns on paper to discuss with the doctors and nurses tomorrow
- D. Offering the client a back rub and a warm cup of milk
Correct Answer: B
Rationale: Offering to stay and discuss concerns is therapeutic, providing emotional support and addressing the client's fears.