Nokea
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.
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If the client is allergic to penicillin, the nurse must question a medical order for which type of antibiotic?
- A. An aminoglycoside such as gentamicin sulfate (Garamycin)
- B. A cephalosporin such as cefaclor (Ceclor)
- C. A tetracycline such as doxycycline (Vibramycin)
- D. A sulfonamide such as trimethoprim/sulfamethoxazole (Bactrim)
Correct Answer: B
Rationale: Cephalosporins (e.g., cefaclor) have a cross-sensitivity with penicillin, risking allergic reactions in penicillin-allergic clients. The other antibiotics listed do not share this cross-reactivity.
The Muslim client practicing Islam is hospitalized following surgical repair of a hip fracture. The client informs the nurse about wishing to observe Ramadan, which is occurring now. Which statement by the nurse is respectful of the client's faith beliefs?
- A. I'm going to uncover your hip and leg now to check the incision and your pulses.'
- B. A dietitian helps to plan your meals so that meat and dairy products are not together.'
- C. I've asked that physical therapy be postponed until around 3 p.m., when Ramadan ends.'
- D. I should let the care team know not to bring food or beverages from sunrise to sunset.'
Correct Answer: D
Rationale: D. During the month of Ramadan, those of the Islamic faith do not eat or drink from sunrise to sunset.
Which response by the nurse is most appropriate when the mother, concerned about her unborn daughter developing DMD, states that her brother and son have DMD?
- A. "You already have one child with muscular dystrophy; it's unlikely you'll have another."
- B. "Your brother and son have DMD; it's unlikely that you'll have another child with DMD."
- C. "As many as one-third of children born with DMD have no family history of the disease."
- D. "If your unborn child is a girl, she may carry the gene, but she will not develop DMD."
Correct Answer: D
Rationale: DMD is X-linked; females may be carriers but do not develop the disease.
The client is three (3) hours postoperative left AKA. The client tells the nurse, 'My left foot is killing me. Please do something.' Which intervention should the nurse implement?
- A. Explain to the client his left leg has been amputated.
- B. Medicate the client with a narcotic analgesic immediately.
- C. Instruct the client on how to perform biofeedback exercises.
- D. Place the client's residual limb in the dependent position.
Correct Answer: B
Rationale: Phantom limb pain is treated with analgesics; narcotics provide immediate relief. Explaining the amputation dismisses pain, biofeedback is long-term, and dependent positioning is inappropriate.
Which interventions should the nurse implement for the client diagnosed with an open fracture of the left ankle? Select all that apply.
- A. Apply an immobilizer snugly to prevent edema.
- B. Apply an ice pack for 10 minutes and remove for 20 minutes.
- C. Place the extremity in the dependent position to allow drainage.
- D. Obtain an x-ray of the ankle after applying the immobilizer.
- E. Administer tetanus toxoid, 0.5 mL intramuscularly, in the deltoid.
Correct Answer: B,D,E
Rationale: Ice reduces swelling, x-ray confirms fracture, and tetanus prevents infection in open fractures. Tight immobilizers risk neurovascular compromise, and dependent positioning worsens edema.