Nokea
The nurse finds a client smoking marijuana in the hospital and tells her that no smoking or use of drugs is allowed in the facility. The client responds by shouting, 'What business is it of yours? Leave me alone!' Which of the following initial responses is the best for the nurse to use to defuse the situation?
- A. It's my business because I'm your nurse.'
- B. If you don't put that out immediately, I will call security.'
- C. You are violating the facility policies and the law!'
- D. I'm sorry, but I have to ask you again to put out your marijuana cigarette.'
Correct Answer: D
Rationale: A calm, polite request to stop (D) de-escalates the situation while reinforcing the rule. Other responses (A, B, C) are confrontational and likely to escalate the client's agitation.
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An AIDS patient has developed a fungal Fusarium infection. The nurse anticipates the physician will order
- A. lamivudine/zidovudine (Combivir).
- B. famciclovir (Famvir).
- C. ciprofloxacin (Cipro).
- D. voriconazole (Vfend)
Correct Answer: D
Rationale: Voriconazole is an antifungal effective against Fusarium. Combivir (antiretroviral), famciclovir (antiviral), and ciprofloxacin (antibacterial) are not appropriate.
A community center is having a health fair. Which of the following main food courses should the nurse recommend as most healthful for a 20-year-old adult whose total cholesterol level is 300 mg/dL?
- A. fettuccine alfredo
- B. fried chicken
- C. grilled cheese sandwich with bacon
- D. natural peanut butter and banana sandwich on whole wheat bread
Correct Answer: D
Rationale: The peanut butter and banana sandwich on whole wheat bread is lower in saturated fats and healthier for managing high cholesterol.
A 4-month-old is brought to the well-baby clinic for immunization. In addition to the DPT and polio vaccines, the baby should receive:
- A. Hib titer
- B. Mumps vaccine
- C. Hepatitis B vaccine
- D. MMR
Correct Answer: C
Rationale: At 4 months, the hepatitis B vaccine is part of the standard immunization schedule, along with DPT and polio vaccines.
The nurse is teaching the parents of an infant with osteogenesis imperfecta. The nurse should explain the need for:
- A. Additional calcium in the infant's diet
- B. Careful handling to prevent fractures
- C. Providing extra sensorimotor stimulation
- D. Frequent testing of visual function
Correct Answer: B
Rationale: Osteogenesis imperfecta causes brittle bones, so careful handling is critical to prevent fractures in infants with this condition.
A client on a mechanical ventilator begins to fight the ventilator. Which medication will be ordered for the client?
- A. Sublimaze (fentanyl)
- B. Pavulon (pancuronium bromide)
- C. Versed (midazolam)
- D. Atarax (hydroxyzine)
Correct Answer: B
Rationale: Pavulon, a neuromuscular blocker, is used to paralyze respiratory muscles in clients fighting the ventilator, ensuring effective ventilation.