Nokea
The nurse is caring for a client in a manic phase of bipolar affective disorder. It is MOST important for the nurse to offer which of the following meals?
- A. Tuna salad sandwich and orange slices.
- B. Bologna sandwich and french fries.
- C. Milkshake and banana.
- D. Fried chicken and tossed salad.
Correct Answer: A
Rationale: Manic clients need portable, nutritious finger foods due to high energy and distractibility. Tuna salad sandwich and orange slices provide balanced nutrition. Options B, C, and D are less suitable: bologna is processed, milkshakes lack variety, and fried chicken is messy.
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The nurse has just returned to the desk and has four phone messages to return.
Which of the following messages should the nurse return FIRST?
- A. A man with swelling of his left wrist following a fall from a ladder two hours ago.
- B. A woman who had a cholecystectomy one week ago and now complains of redness and tenderness at the incision site.
- C. A mother of a child reports that her son's lips are swollen following a fire ant bite.
- D. A man with COPD reports he is coughing up large amounts of green-tinged sputum and has a temperature of 101.2°F (38.4°C).
Correct Answer: C
Rationale: Strategy: Remember the ABCs. (1) wrist needs to be x-rayed, not a priority (2) indicates infection, treated with antibiotic (3) correct-potential anaphylactic reaction, administer epinephrine, corticosteroids; treat for shock (4) indicates infection, treat with an antibiotic
A client has been taking furosemide (Lasix) for the past week. The nurse recognizes which finding may indicate the client is experiencing a negative side effect from the medication?
- A. Weight gain of 5 pounds
- B. Edema of the ankles
- C. Gastric irritability
- D. Decreased appetite
Correct Answer: D
Rationale: Decreased appetite. Lasix causes a loss of potassium if a supplement is not taken. Signs and symptoms of hypokalemia include anorexia, fatigue, nausea, decreased GI motility, muscle weakness, and dysrhythmias.
A nurse is assessing a patient in the rehab unit at shift change. The patient has suffered a TBI 3 weeks ago. Which of the following is the most distinguishing characteristic of a neurological disturbance?
- A. LOC (level of consciousness)
- B. Short term memory
- C. #NAME?
- D. #NAME?
Correct Answer: A
Rationale: LOC is the most critical indicator of impaired neurological capabilities.
The nurse is caring for clients in a rehabilitation facility. The nursing team reports that a client recovering from a hip fracture has repeatedly 'transferred herself to the floor.' Which of the following actions, if taken by the nurse, is BEST?
- A. Place the call light within the client's reach.
- B. Remove the footrests from the wheelchair.
- C. Observe the client trying to rise from a sitting to a standing position.
- D. Place a posey vest restraint on the client.
Correct Answer: C
Rationale: Observing the client’s transfer technique identifies the cause of falls, guiding interventions. Options A, B, and D are premature or restrictive.
A five-year-old boy in the playroom.
The school nurse observes a group of preschool children in the playroom. The nurse recognizes which of the following activities as appropriate behavior for a five-year-old boy?
- A. The boy plays with a large truck with another child.
- B. The boy talks on a toy telephone and imitates his father.
- C. The boy works on a puzzle with several other children.
- D. The boy holds and cuddles a large stuffed animal.
Correct Answer: B
Rationale: Strategy: Picture the child. (1) play begins to be cooperative at this age (2) correct-imitative behavior seen at this age (3) too advanced for this age (4) too regressed for this age