Nokea
The client with a myocardial infarction comes to the nurse's station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using?
- A. Rationalization
- B. Denial
- C. Projection
- D. Conversion reaction
Correct Answer: B
Rationale: Denial involves refusing to acknowledge a serious condition.
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The client with varicella will most likely have an order for which category of medication?
- A. Antibiotics
- B. Antipyretics
- C. Antivirals
- D. Anticoagulants
Correct Answer: C
Rationale: Varicella (chickenpox) is a viral infection, and antivirals like acyclovir are commonly prescribed to reduce severity and duration.
A student in a cardiac unit is performing auscultation of a client's heart. The nurse recognizes that the student is performing pulmonic auscultation correctly when the stethoscope is placed:
- A. Between the apex and the sternum
- B. At the fifth intercostal space at the left midclavicular line
- C. At the second intercostal space, left of the sternum
- D. At the manubrium
Correct Answer: C
Rationale: The pulmonic area is auscultated at the second intercostal space, left of the sternum, where the pulmonary valve sounds are best heard.
The nurse is caring for a client who has just returned from surgery for an ascending colostomy. The nurse plans to include reinforcement teaching for the client and spouse. Which statements should the nurse include in the teaching? Select all that apply.
- A. The colostomy will begin functioning within 24 hours.
- B. A large amount of bleeding may be present at the stoma site.
- C. The first stools will be liquid and will gradually become more formed.
- D. A healthy stoma is reddish-pink and moist and protrudes about 2 cm from the abdominal wall.
Correct Answer: C,D
Rationale: A healthy stoma is reddish-pink, moist, and protrudes slightly (D). Initial stools are liquid, becoming formed over time (C). Function typically starts in 2-5 days, not 24 hours (A), and significant bleeding (B) is abnormal.
The nurse is performing discharge diet teaching to a client with a stage 1 decubitus ulcer on the coccyx. Which diet selection by this client would indicate that the client has a clear understanding of the proper diet for healing of a decubitus ulcer?
- A. Tossed salad, milk, and a slice of caramel cake
- B. Vegetable soup and crackers, and a glass of tea
- C. Baked chicken breast, broccoli, wheat roll, and an orange
- D. Hamburger, French fries, and corn on the cob
Correct Answer: C
Rationale: Healing a decubitus ulcer requires a diet high in protein, vitamins (especially C and A), and minerals like zinc. Baked chicken (protein), broccoli (vitamin A), wheat roll (carbohydrates), and orange (vitamin C) support tissue repair. The other options lack sufficient protein or include high-sugar/fat items that don't aid healing.
A labor and delivery nurse is caring for a client in active labor. The fetal monitor shows late decelerations. The nurse should first
- A. place the client in high-Fowler's position in preparation to push.
- B. place the client in left lateral recumbent position.
- C. increase the rate of IV Pitocin.
- D. call the physician and report fetal distress.
Correct Answer: B
Rationale: Late decelerations indicate uteroplacental insufficiency. The left lateral position improves placental perfusion, addressing the immediate cause.