Nokea
The client is being admitted for surgery. During the admission assessment, the client states that she usually has 8 to 10 alcoholic drinks a day. How should the nurse reply?
- A. What type of alcohol do you drink?
- B. How long have you been drinking alcohol?
- C. When was your last drink?
- D. Why do you drink so much?
Correct Answer: C
Rationale: Admitting to 8 to 10 alcoholic drinks a day is suggestive of alcoholism. It is important to know when the client last had a drink of alcohol in order to anticipate the onset of withdrawal symptoms. The type of alcohol the client drinks, how long the client has been drinking, and why the client drinks are not the key issues. The key issue is when to anticipate withdrawal symptoms.
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A man who had a cerebrovascular accident has expressive aphasia. Which approach will help communication the most?
- A. The nurse should write to the client and the client should write back.
- B. The nurse should anticipate the client's needs as much as possible.
- C. The nurse should encourage the client to speak as much as possible.
- D. A family member should stay with the client and express the client's needs to the nurse.
Correct Answer: C
Rationale: Encouraging speech practice aids communication recovery in expressive aphasia, fostering independence. Writing, anticipating needs, or relying on family are less effective.
The nurse is teaching a young woman how to perform breast self-examination. Which comment, if made by the client, indicates that the teaching has been effective?
- A. I should examine my breasts every year.'
- B. I need to see the doctor every six months for a breast exam.'
- C. I don't need to worry about breast cancer for a few years.'
- D. I should examine all parts of my breasts while both lying down and standing up.'
Correct Answer: D
Rationale: Effective breast self-examination involves checking all breast areas in both lying and standing positions monthly. Yearly exams, frequent doctor visits, or delaying concern are incorrect.
A patient with hyperparathyroidism.
Which symptom is MOST important for the nurse to report to the next shift?
- A. Abdominal discomfort.
- B. Hematuria.
- C. Muscle weakness.
- D. Diaphoresis.
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to hyperparathyroidism. (1) sign of hyperparathyroidism but does not require reporting (2) correct-hematuria is a sign of renal calculi; 55% of hyperparathyroid clients have renal stones (3) sign of hyperparathyroidism but does not require reporting (4) sign of hyperparathyroidism but does not require reporting
The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data?
- A. Impaired gas exchange related to acute infection and sputum production
- B. Ineffective airway clearance related to sputum production and ineffective cough
- C. Ineffective breathing pattern related to acute infection
- D. Anxiety related to hospitalization and role conflict
Correct Answer: B
Rationale: Ineffective airway clearance is defined as the inability to cough effectively, directly supported by the assessment data of crackles and ineffective cough.
A woman is scheduled for a breast biopsy. She is crying and says, 'I am so upset because I watched my mother die from ovarian cancer.' What is the most appropriate nursing diagnosis?
- A. Fear
- B. Anxiety
- C. Ineffective family coping
- D. Spiritual distress
Correct Answer: A
Rationale: Fear of cancer due to her mother's death is the most specific diagnosis, addressing her emotional response to the biopsy.