Nokea
The client with cancer refuses to care for herself. Which action by the nurse would be best?
- A. Alternate nurses caring for the client so that the staff will not get tired of caring for this client.
- B. Talk to the client and explain the need for self-care.
- C. Explore the reason for the lack of motivation seen in the client.
- D. Talk to the physician about the client's lack of motivation.
Correct Answer: C
Rationale: Exploring the reason for the client’s refusal to self-care (e.g., depression, pain, or fear) is the best approach, as it addresses the underlying cause and guides interventions. Alternating nurses avoids the issue, explaining self-care may not address motivation, and consulting the physician is secondary.
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A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
- A. Give fluids if the client requests them.
- B. Assess skin integrity and circulation of extremities before applying restraints and as they are removed.
- C. Measure vital signs at least every 4 hours.
- D. Release restraints every 2 hours for client to exercise.
Correct Answer: D
Rationale: Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.
The nurse is preparing to administer a dose of penicillin to a client with a streptococcal infection. Which assessment is most important before administration?
- A. Allergy history
- B. Blood pressure
- C. Temperature
- D. Respiratory rate
Correct Answer: A
Rationale: Penicillin has a high risk of allergic reactions, including anaphylaxis. Assessing allergy history is critical before administration. Vital signs are monitored but are less specific to penicillin risks.
The nurse is caring for a client with a diagnosis of postpartum depression. Which intervention is most appropriate?
- A. Refer to a psychiatrist
- B. Administer antibiotics
- C. Monitor fetal heart tones
- D. Administer tocolytics
Correct Answer: A
Rationale: Postpartum depression requires mental health intervention such as referral to a psychiatrist for therapy or medication. Antibiotics fetal monitoring and tocolytics are irrelevant to this condition.
The parents of a 2-year-old child are ready to begin toilet training activities with him. His parents feel he is ready to train because he is now 2 years old. What would the nurse identify as readiness in this child?
- A. Patience by the child when wearing soiled diapers
- B. Communicating the urge to defecate or urinate
- C. The child awakening wet from his naps
- D. The age at which the child's siblings were trained
Correct Answer: B
Rationale: A child must be able to use verbal or nonverbal skills to communicate needs, indicating readiness for toilet training.
Discharge teaching for the client who has a total gastrectomy should include which of the following?
- A. Need for the client to increase fluid intake to 3000 mL/day
- B. Follow-up visits every 3 weeks for the first 6 months
- C. B12 injections needed for the rest of the client's life
- D. Need to eat three full meals with plenty of fiber per day
Correct Answer: C
Rationale: There will be no need to increase fluid intake excessively, because dumping syndrome could present a problem. Follow-up visits every 3 weeks are not a standard recommendation. Follow-up visits will be highly individualized. With removal of the stomach, intrinsic factor will no longer be produced. Intrinsic factor is necessary for vitamin B12 absorption. Parenteral injections of B12 will be needed on a monthly basis for the rest of the person's life. Smaller, more frequent meals, rather than large, bulky meals, are recommended to prevent problems with dumping syndrome.