Nokea
The nurse is caring for a 5-year-old client with sickle cell disease who is experiencing an episode of acute pain. The client has shortness of breath, nausea with vomiting, and severe generalized body and joint pain. Which of the following findings requires immediate intervention?
- A. enlarged spleen on palpation
- B. hemoglobin level of 9.0 g/dL (90 g/L)
- C. bilateral swelling of the hands and feet
- D. pain rated as 8 on the Wong-Baker FACES Scale
Correct Answer: A
Rationale: An enlarged spleen may indicate splenic sequestration, a life-threatening complication requiring immediate intervention.
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A nurse is caring for a client following the delivery of a stillborn infant. Which of the following actions should the nurse take? Select all that apply.
- A. Ask the parents if they would like to help bathe the infant
- B. Discourage the parents from naming the infant
- C. Discuss the importance of organ donation with the parents
- D. Encourage the parents and family members to hold the infant
- E. Offer to obtain handprints, footprints, and photographs of the infant
Correct Answer: A,D,E
Rationale: Bathing, holding, and obtaining mementos support grieving. Naming is a personal choice, and organ donation discussions may be inappropriate at this time.
A woman who is pregnant for the first time asks the nurse when during pregnancy is the best time to take Lamaze classes. What should the nurse respond?
- A. During the first trimester
- B. During the second trimester
- C. During the third trimester
- D. Whatever fits into your schedule
Correct Answer: B
Rationale: The second trimester is ideal for Lamaze classes, as it allows time to learn techniques before labor while avoiding early pregnancy discomforts and late-term fatigue.
The nurse finds a person unresponsive on the floor. What is the initial nursing action?
- A. Start chest compressions
- B. Assess respirations and pulse
- C. Place on a hard surface
- D. Start mouth-to-mouth breathing
Correct Answer: B
Rationale: Assessing respirations and pulse determines if CPR is needed, per ACLS guidelines. Compressions, positioning, or breathing are premature without confirming unresponsiveness and absence of pulse/breathing.
A client with a recent spinal cord injury is experiencing dysreflexia and is noted to have a BP of $240 / 110$. The nurse's initial response should be to:
- A. Check the client's pulse and respiratory rate.
- B. Elevate the client's head to a $45^{\circ}$ angle.
- C. Place the client flat and supine.
- D. Administer antihypertensive and recheck BP in 15 minutes.
Correct Answer: B
Rationale: Elevating the head to a 45° angle helps reduce blood pressure in autonomic dysreflexia by promoting venous return and reducing intracranial pressure.
A female client is admitted for a breast biopsy. She says, tearfully to the nurse, 'If this turns out to be cancer and I have to have my breast removed, my partner will never come near me.' The nurse's best response would be which of these statements?
- A. I hear you saying that you have a fear for the loss of love.'
- B. You sound concerned that your partner will reject you.'
- C. Are you wondering about the effects on your sexuality?'
- D. Are you worried that the surgery will lead to changes?'
Correct Answer: D
Rationale: This is a general lead-in type of response that encourages further discussion without focusing on an area that the nurse, but possibly not the client, feels is a problem.