Nokea
The initial response by the nurse to a delusional client who refuses to eat because of a belief that the food is poisoned is
- A. You think that someone wants to poison you?
- B. Why do you think the food is poisoned?
- C. These feelings are a symptom of your illness.
- D. You're safe here. I won't let anyone poison you.
Correct Answer: A
Rationale: You think that someone wants to poison you? This acknowledges the client's perception, opening discussion and expressing doubt.
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A client is diagnosed with lung cancer and undergoes a pneumonectomy.
In the immediate postoperative period, which of the following nursing assessments is MOST important?
- A. Presence of breath sounds bilaterally.
- B. Position of the trachea in the sternal notch.
- C. Amount and consistency of sputum.
- D. Increase in the pulse pressure.
Correct Answer: B
Rationale: Strategy: Determine how each answer choice relates to a pneumonectomy. (1) on the surgical side, breath sounds will be absent (2) correct-position of the trachea should be evaluated; with a tracheal shift, an increase in pressure could occur on the operative side and could cause pressure against the mediastinal area (3) important to observe but not as high a priority (4) does not relate to the situation
A male client is preparing for discharge following an acute myocardial infarction. He asks the nurse about his sexual activity once he is home. What would be the nurse's initial response?
- A. Give him written material from the American Heart Association about sexual activity with heart disease
- B. Answer his questions accurately in a private environment
- C. Schedule a private, uninterrupted teaching session with both the client and his wife
- D. Assess the client's knowledge about his health problems
Correct Answer: D
Rationale: The nursing process is continuous and cyclical in nature. When a client expresses a specific concern, the nurse performs a focused assessment to gather additional data prior to planning and implementing nursing interventions.
The nurse is caring for a client with a history of burn injuries.
- A. Which intervention is most important for a client with major burn injuries?
- B. Maintain strict aseptic technique.
- C. Administer oral fluids to prevent dehydration.
- D. Apply cold compresses to burn sites.
- E. Restrict protein intake.
Correct Answer: A
Rationale: Strict aseptic technique prevents infection, a major cause of mortality in burn patients due to loss of skin barrier. IV fluids are used, cold compresses worsen tissue damage, and high-protein diets support healing.
A college student comes to the college health services with complaints of a severe headache, nausea, and photophobia. The physician orders a complete blood count (CBC) and a lumbar puncture (LP). Which of the following lab results would the nurse expect if a diagnosis of bacterial meningitis were made?
- A. Cerebrospinal fluid (CSF) cloudy, Hgb 13 g/dL, Hct 38%, WBC 18,000/mm³.
- B. CSF with RBCs present, Hgb 10 g/dL, Hct 37%, WBC 8,000/mm³.
- C. CSF cloudy, Hgb 12 g/dL, Hct 37%, WBC 7,000/mm³.
- D. CSF clear, Hgb 15 g/dL, Hct 40%, WBC 11,000/mm³.
Correct Answer: A
Rationale: CSF normally clear, colorless; normal WBC 5,000-10,000 per cubic millimeter, normal Hgb (male 13.5-17.5 g/dL, female 12-16 g/dL), normal Hct (male 41-53%, female 36-46%)
A client with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. The most therapeutic response by the nurse to his refusal is
- A. You need to take your medicine, this is how you get well.
- B. If you refuse your medicine, we'll just have to give you a shot.
- C. What is it about the medicine that you don't like?
- D. I can see that you are uncomfortable right now, I'll wait until tomorrow.
Correct Answer: C
Rationale: What is it about the medicine that you don't like? This fosters trust and open communication, encouraging the client to express concerns.