Nokea
The client says to the nurse, 'I don't see why I should live any longer.' How should the nurse respond initially?
- A. Ask the client why she doesn't want to live any longer
- B. Ask the client if she is considering suicide
- C. Tell the client that life is precious and worth living
- D. Help the client see the good things that she has in her life
Correct Answer: B
Rationale: Expressing a desire to not live suggests suicidal ideation; directly asking about suicide assesses risk and guides intervention. Exploring reasons, affirming life, or highlighting positives are secondary.
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A client with suspected Addison's disease is scheduled for a rapid corticotrophin stimulation test. Which of the following will the nurse include in her teaching?
- A. The need to limit fluid intake
- B. The need for periodic blood samples
- C. The need for collection of a 24-hour urine
- D. The need for frequent IV injections
Correct Answer: B
Rationale: The rapid corticotrophin stimulation test requires periodic blood samples to measure cortisol levels before and after ACTH administration.
The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is
- A. Eat a balanced diet for your age.
- B. Increase your intake of protein and Vitamin A.
- C. Decrease fatty foods from your diet.
- D. Do not use caffeine in any form, including chocolate.
Correct Answer: A
Rationale: Eat a balanced diet for your age. There are no recommended additions and subtractions from the diet for acne management.
A four-month-old child is admitted with a tentative diagnosis of meningitis.
- A. What is the most important nursing action during a lumbar puncture for a four-month-old with suspected meningitis?
- B. Appropriately restrain the child.
- C. Instruct the parents about the procedure.
- D. Provide support to the child.
- E. Elevate the head of the bed.
Correct Answer: A
Rationale: Restraining the child during a lumbar puncture prevents movement, reducing the risk of spinal trauma. Parental instruction and emotional support are important but secondary, and elevating the head is inappropriate for positioning.
A client with a diagnosis of Methicillin resistant Staphylococcus aureus (MRSA) has died. Which type of precautions is appropriate to use when performing postmortem care?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Compromised host precautions
Correct Answer: C
Rationale: The resistant bacteria remain alive for up to 3 days after the client dies. Therefore, contact precautions must still be implemented.
The nurse is caring for a client who is receiving a blood transfusion. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.4°F (38°C).
- B. Heart rate of 90 bpm.
- C. Respiratory rate of 18 breaths/min.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: A
Rationale: A temperature of 100.4°F during a blood transfusion suggests a transfusion reaction, such as febrile non-hemolytic reaction, requiring immediate cessation of the transfusion. Options B, C, and D are normal: heart rate 90 bpm, respiratory rate 18 breaths/min, and blood pressure 120/80 mmHg do not indicate complications.