Nokea
The nurse in the mental health unit is talking with several clients during group therapy. A client becomes angry and throws a fire extinguisher at another client. Which of the following actions would be a priority for the nurse to take?
- A. Activate the rapid response team.
- B. Approach the client calmly and acknowledge the client's feelings.
- C. Escort other clients away from the area.
- D. Inform the client that the action was dangerous and unacceptable.
Correct Answer: C
Rationale: Ensuring safety by escorting others away (C) is the priority. Rapid response (A) may be premature, approaching the client (B) risks escalation, and informing of consequences (D) is secondary.
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The nurse is providing home care to an elderly woman who had a cerebrovascular accident several weeks ago. All of the following need to be done. Which should the nurse plan to do first?
- A. Auscultate lung fields
- B. Hygienic care
- C. Assist with ambulation
- D. Range-of-motion (ROM) exercises
Correct Answer: A
Rationale: Auscultating lung fields assesses respiratory status, a priority post-CVA to detect complications like pneumonia or atelectasis. Hygienic care, ambulation, and ROM are secondary.
Which of the following activities would be best tolerated by a client with muscular dystrophy?
- A. Swimming
- B. Riding a bicycle
- C. Playing golf
- D. Skating
Correct Answer: A
Rationale: Swimming is low-impact and supports muscles, making it the best activity for a client with muscular dystrophy, which causes muscle weakness.
The nurse is screening clients for those at risk of developing nephrolithiasis. Which of the following factors would increase a client's risk of developing nephrolithiasis?
- A. gout
- B. dehydration
- C. hypokalemia
- D. thrombocytopenia
- E. hyperparathyroidism
Correct Answer: A,B,E
Rationale: Gout (A), dehydration (B), and hyperparathyroidism (E) increase nephrolithiasis risk due to uric acid, concentrated urine, and calcium imbalances, respectively. Hypokalemia (C) and thrombocytopenia (D) are unrelated.
The graduate nurse (GN) is caring for a client with a fractured femur in balanced suspension skeletal traction. Which action by the GN will require the precepting nurse to intervene?
- A. Encourages the client to drink plenty of water and choose high-fiber foods from the diet menu
- B. Lifts the traction weights while the unlicensed assistive personnel provide a bed bath and linen change
- C. Monitors the incision and pin insertion sites for erythema, drainage, and malodor
- D. Performs Doppler ultrasound pulse checks in the affected leg every hour for the first 24 hours after surgery
Correct Answer: B
Rationale: Lifting traction weights (B) disrupts alignment and healing, requiring intervention. Hydration and fiber (A), monitoring sites (C), and pulse checks (D) are appropriate.
The nurse is talking with a client who is scheduled for a lumbar puncture. Which of the following statements by the client would require follow-up?
- A. I will need to lie on my stomach during the procedure.
- B. I should go to the bathroom to urinate before the procedure.
- C. I understand that a needle will be inserted between the bones in my lower spine during the procedure.
- D. I may experience a sharp pain radiating down my leg during the procedure, but it should pass quickly.
Correct Answer: A
Rationale: Lumbar punctures are typically performed in a lateral or sitting position, not prone (A), requiring clarification. Urinating beforehand (B), needle insertion (C), and transient pain (D) are correct.