Nokea
The nurse is assessing the client diagnosed with chronic gastritis. Which symptom(s) support this diagnosis?
- A. Rapid onset of midsternal discomfort.
- B. Epigastric pain relieved by eating food.
- C. Dyspepsia and hematemesis.
- D. Nausea and projectile vomiting.
Correct Answer: C
Rationale: Dyspepsia (indigestion) and hematemesis (vomiting blood) are symptoms of chronic gastritis due to mucosal irritation. Midsternal pain, pain relief with food, and projectile vomiting are less typical.
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The 36-year-old female client diagnosed with anorexia nervosa tells the nurse 'I am so fat. I won't be able to eat today.' Which response by the nurse is most appropriate?
- A. Can you tell me why you think you are fat?
- B. You are skinny. Many women wish they had your problem.
- C. If you don't eat, we will have to restrain you and feed you.
- D. Not eating might cause physical problems.
Correct Answer: A
Rationale: Asking why the client feels fat explores distorted body image, a therapeutic approach in anorexia. Dismissing feelings, threatening restraints, or stating consequences are nontherapeutic.
The client had Billroth II surgery 24 hours ago. The client’s son approaches the nurse in the hallway and asks for information regarding his father’s condition. The wife is listed as the designated contact person. Which nurse response is best?
- A. “What has the surgeon told you about your father’s condition?”
- B. “Let’s both go into your father’s room and ask him how he feels.”
- C. “Let’s go to a more private place to discuss your father’s condition.”
- D. “Let’s review your father’s medical record information together.”
Correct Answer: B
Rationale: A. Discussing client information in a hospital hallway is inappropriate; individuals passing by could overhear confidential client information. B. Going into the client’s room together allows the client to determine if he wants to disclose information and how much information he wants to disclose. C. Even if in a private location, the nurse should not share confidential client information with anyone unless the client has specifically given permission. D. The nurse should not review the medical record of the client with a family member without permission. Some facilities require the client to complete a form requesting permission to review his or her own medical records.
The client diagnosed with inflammatory bowel disease has a serum potassium level of 3.4 mEq/L. Which action should the nurse implement first?
- A. Notify the health-care provider (HCP).
- B. Assess the client for muscle weakness.
- C. Request telemetry for the client.
- D. Prepare to administer potassium IV.
Correct Answer: B
Rationale: A potassium level of 3.4 mEq/L is slightly low, warranting assessment for symptoms like muscle weakness, which could indicate hypokalemia severity. Notification or intervention would follow based on clinical findings, but assessment is the first step.
Which priority teaching information should the nurse discuss with the client to help prevent contracting hepatitis B?
- A. Explain the importance of good hand washing.
- B. Recommend the client take the hepatitis B vaccine.
- C. Tell the client not to ingest unsanitary food or water.
- D. Discuss how to implement Standard Precautions.
Correct Answer: B
Rationale: The hepatitis B vaccine is the most effective way to prevent hepatitis B, a bloodborne virus. Handwashing and food safety are less relevant, and Standard Precautions are for healthcare settings.
Which task is most appropriate for the nurse to delegate to the unlicensed assistive personnel (UAP)?
- A. Draw the serum liver function test.
- B. Evaluate the client’s intake and output.
- C. Perform the bedside glucometer check.
- D. Help the ward clerk transcribe orders.
Correct Answer: C
Rationale: Performing a glucometer check is within the UAP’s scope with proper training. Drawing blood, evaluating intake/output, and transcribing orders require RN skills.