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The nurse is caring for a client who had a surgical excision and biopsy of a tumor. The biopsy results show that the tumor is malignant, but the client has not yet been informed by the health care provider. The client asks the nurse, 'Am I going to die?' Which of the following responses would be appropriate for the nurse to make?
- A. You seem upset. Tell me more about how you are feeling about this situation.
- B. I understand that you feel anxious. Maybe watching television will help you relax.
- C. Waiting for test results can be very stressful. I am sure that it will all work out.
- D. The biopsy results show that you have cancer. However, many cancers are treatable.
Correct Answer: A
Rationale: Exploring the client's feelings is supportive and appropriate, as the nurse should not disclose results before the provider.
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The clinic nurse is collecting data on a client at 22 weeks gestation during a prenatal visit. Which finding is most concerning?
- A. Client has not consistently taken prenatal vitamins
- B. Client is taking lisinopril to control hypertension
- C. Client reports a whitish vaginal discharge
- D. Client reports mild cramping pain in the lower abdomen
Correct Answer: B
Rationale: Lisinopril is contraindicated in pregnancy due to the risk of fetal harm and requires immediate discontinuation.
A client with an implantable cardioverter defibrillator (ICD) develops ventricular tachycardia (VT) with a pulse while admitted to the medical-surgical unit. The ICD fires multiple times without successfully stopping the VT, causing the client to become confused and difficult to rouse. Which action by the nurse is appropriate?
- A. Attempt to stimulate a vagal response by having the client cough
- B. Deactivate the client's implantable cardioverter defibrillator with an external magnet
- C. Obtain a STAT 12-lead ECG to verify the cardiac rhythm
- D. Prepare for synchronized cardioversion with the external defibrillator
Correct Answer: D
Rationale: Persistent VT causing altered mental status requires synchronized cardioversion to restore normal rhythm.
The nurse is caring for a client with detoxification from alcohol. Which medication is used in the treatment of alcohol withdrawal?
- A. Antabuse (disulfiram)
- B. Romazecon (flumazenil)
- C. Dolophine (methodone)
- D. Ativan (lorazepam)
Correct Answer: D
Rationale: Ativan (lorazepam), a benzodiazepine, is used to manage alcohol withdrawal symptoms like seizures and agitation. Antabuse deters drinking, flumazenil reverses benzodiazepines, and methadone treats opioid withdrawal.
The nurse is caring for a woman who is admitted for a hysterectomy. The woman does not speak English. No staff members speak the client's language. Which approach by the nurse would be most appropriate when communicating with the client about her care before and after the surgery?
- A. Ask the woman's 8-year-old daughter who speaks English to interpret.
- B. Draw pictures and gesture when speaking to the client.
- C. Speak very slowly when giving the client instructions.
- D. Request an interpreter from social services.
Correct Answer: D
Rationale: The nurse should request an interpreter from social services to ensure accurate communication. Using a child to interpret is inappropriate due to medical terminology and privacy concerns. Pictures, gestures, or slow speech in English are insufficient for surgical care discussions.
An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused by
- A. Tachypnea
- B. Acidic byproducts
- C. Aspirin poisoning and dehydration
- D. Hyperpyrexia
Correct Answer: A
Rationale: Tachypnea. Stimulation of respiratory center leads to hyperventilation, thus decreasing CO2 levels which causes respiratory alkalosis.