Nokea
The nurse is assisting with care of a client with blunt head injury admitted for observation, including hourly neurologic checks. At 1:00 AM, the client reports a headache; the neurologic check is normal, and the nurse administers acetaminophen prn. At 2:00 AM, the client appears to be sleeping. What action does the nurse anticipate taking?
- A. Arouse the client and ask what the current month is
- B. Awaken the client and check for paresthesia
- C. Document 'relief apparently obtained' and recheck at 3:00 AM
- D. Let the client sleep but verify respiratory rate
Correct Answer: A
Rationale: Hourly neurologic checks require arousing the client to assess orientation (A). Checking paresthesia (B), assuming relief (C), or only verifying respiratory rate (D) do not meet monitoring requirements.
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After inserting an indwelling catheter into an adult male, the nurse secures the catheter by:
- A. taping it lateral to the client's thigh.
- B. taping it upward to the client's abdomen.
- C. taping it downward to the client's thigh.
- D. making a loop with the tubing and taping the tubing to the client's thigh.
Correct Answer: A
Rationale: Taping the catheter laterally to the thigh prevents tension or dislodgement while allowing mobility. Upward or downward taping risks kinking, and looping increases infection risk.
The nurse has reinforced teaching with a client who has rheumatoid arthritis and is receiving methotrexate. Which of the following statements by the client would require follow-up?
- A. I will avoid drinking alcoholic beverages while taking methotrexate.'
- B. I should take precautions to prevent pregnancy while taking methotrexate.'
- C. I should avoid large crowds and people who are ill while taking methotrexate.'
- D. I will avoid consuming foods high in folic acid that will decrease the effectiveness of methotrexate.'
Correct Answer: D
Rationale: Avoiding alcohol (A), preventing pregnancy (B), and avoiding crowds (C) are correct. Avoiding folic acid (D) is incorrect, as methotrexate often requires folic acid supplementation to reduce side effects.
A nurse aide is taking care of a 2 year-old child with Wilm's tumor. The nurse aide asks the nurse why there is a sign above the bed that says DO NOT PALPATE THE ABDOMEN? The best response by the nurse would be which of these statements?
- A. Touching the abdomen could cause cancer cells to spread.'
- B. Examining the area would cause difficulty to the child.'
- C. Pushing on the stomach might lead to the spread of infection.'
- D. Placing any pressure on the abdomen may cause an abnormal experience.'
Correct Answer: A
Rationale: Manipulation of the abdomen can lead to dissemination of cancer cells to nearby and distant areas. Bathing and turning the child should be done carefully.
The nurse is discussing child safety with a group of mothers of toddlers. Which statement indicates a need for more instruction?
- A. My child should be in the back seat in a front-facing car seat.'
- B. My little one needs constant supervision.'
- C. My child eats finger foods.'
- D. I should put my medicines on a high shelf.'
Correct Answer: A
Rationale: Toddlers (under 2 years) should be in rear-facing car seats for safety; front-facing is incorrect, indicating a need for further instruction.
Which therapeutic communication skill used by the nurse is most likely to encourage a depressed client to vent feelings?
- A. Direct confrontation
- B. Reality orientation
- C. Projective identification
- D. Active listening
Correct Answer: D
Rationale: Active listening. This skill, along with silence, encourages the client to verbalize feelings.