Nokea
The client states, 'My discharge plan leaves me with a lot to do. I don't think I can do it. I'm never good at doing things.' The nurse knows the client lacks:
- A. maturation.
- B. organization.
- C. readiness to learn.
- D. self-efficacy.
Correct Answer: D
Rationale: Expressing doubt in ability to manage the discharge plan indicates low self-efficacy, a belief in one's capacity to execute tasks.
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Epoetin alfa (Epogen) is prescribed for a client who is on dialysis. When teaching the client about the drug, the nurse should plan to include which information about the drug?
- A. The drug is given to help the kidneys produce urine.
- B. The drug is given because the kidneys can no longer get rid of waste products.
- C. The drug replaces natural erythropoietin, which can no longer be produced when the kidney is in failure.
- D. The drug is given to the client to improve athletic ability.
Correct Answer: C
Rationale: Epoetin alfa replaces erythropoietin, deficient in kidney failure, to stimulate red blood cell production, correcting anemia. It does not affect urine production, waste removal, or athletic performance.
When a patient return from the recovery room following a subtotal thyroidectomy, the nurse should immediately
inspect the incision.
- A. instruct the patient not to speak.
- B. keep the patient supine for 24 hours.
- C. place a tracheostomy set at the bedside.
Correct Answer: D
Rationale: Thyroid surgery sometimes results in accidental removal of the parathyroid glands. A resultant hypocalcemia may lead to contraction of the glottis, causing airway obstruction; edema also causes obstruction. Having a tracheostomy set ready is critical.
A new mother has some questions about PKU.
Which of the following statements made by the nurse is correct regarding PKU?
- A. An amniocentesis is required prior to delivery.
- B. PKU test is performed soon after birth.
- C. PKU is preventable if the mother eats adequate amount of protein during pregnancy.
- D. The effects of PKU are irreversible
Correct Answer: B
Rationale: The PKU test is performed shortly after birth to detect phenylalanine levels.
Which of the following findings is most typical of a client with a fractured hip?
- A. Pain in the hip and affected leg
- B. Diminished sensation in the affected leg
- C. Absence of pedal and femoral pulses in the affected extremity
- D. Disalignment of the affected extremity
Correct Answer: A
Rationale: Pain in the hip and leg is the most typical symptom of a hip fracture. Diminished sensation, absent pulses, or disalignment may occur but are less common.
The nurse should recognize that further teaching is needed when a patient with glaucoma states, 'it would be dangerous for me to:
The nurse should recognize that further teaching is needed when a patient with glaucoma states, 'it would be dangerous for me to:
- A. use any sedatives.
- B. become constipated.
- C. use atropine in any form.
- D. release my emotions by crying.
Correct Answer: C
Rationale: Atropine increases intraocular pressure, worsening glaucoma, indicating correct understanding.