Nokea
The nurse is caring for a client who experienced a sexual assault and has posttraumatic stress disorder. The client states, 'It is all my fault. I should not have accepted a drink from a stranger I met at a bar.' Which of the following responses would be most appropriate for the nurse to make?
- A. Those thoughts are not good for you. You should try to stop thinking about the assault.
- B. You have to stop blaming yourself for the assault so you can move on with your life.
- C. It may take time to overcome your thoughts and feelings related to the assault.
- D. You could not have anticipated the assault. You did not deserve or ask for it.
Correct Answer: D
Rationale: This response validates the client's feelings while gently correcting self-blame, reinforcing that the assault was not their fault and promoting a supportive therapeutic environment.
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The nurse is caring for assigned clients. Which of the following clients should the nurse check first?
- A. client who had a cholecystectomy and is reporting incisional pain as 5 on a scale of 1-10
- B. client who had an open reduction of the right femur and is reporting nausea
- C. client with type 1 diabetes mellitus and a blood glucose level of 55 mg/dL (3.1 mmol/L)
- D. client with type 2 diabetes mellitus and a blood glucose level of 250 mg/dL (13.9 mmol/L)
Correct Answer: C
Rationale: A blood glucose level of 55 mg/dL indicates severe hypoglycemia, a life-threatening condition requiring immediate intervention to prevent seizures or coma.
The nurse is caring for a client with a vascular access for hemodialysis. Which of these findings necessitates immediate action by the nurse?
- A. pruritic rash
- B. dry, hacking cough
- C. chronic fatigue
- D. elevated temperature
Correct Answer: D
Rationale: It is a priority to report this finding since clients on hemodialysis are prone to infection, and the first sign is an elevated temperature.
A client's admission urinalysis shows the specific gravity value of 1.039. Which of the following assessment data would the nurse expect to find when assessing this client?
- A. Moist mucous membranes
- B. Urinary frequency
- C. Poor skin turgor
- D. Increased blood pressure
Correct Answer: C
Rationale: Poor skin turgor. The specific gravity value is high, indicating dehydration. Poor skin turgor (tenting of the skin) is consistent with this problem.
A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. The nurse should reinforce teaching about which intervention related to the drug's adverse effects?
- A. Have an ophthalmologic examination every 6 months
- B. Take the medication on an empty stomach
- C. Take vitamin D and calcium supplements
- D. Wear a MedicAlert bracelet
Correct Answer: A
Rationale: Hydroxychloroquine can cause retinal toxicity. Regular ophthalmologic exams every 6 months are essential to monitor for early signs of retinal damage.
A nurse is admitting a client at 42 weeks gestation to the labor and delivery unit for induction of labor. What is a predictor of a successful induction?
- A. Bishop score of 10
- B. Firm and posterior cervix
- C. History of precipitous labor
- D. Reactive nonstress test
Correct Answer: A
Rationale: A Bishop score of 10 indicates a favorable cervix (soft, dilated, effaced, anterior), predicting a higher likelihood of successful induction.