Nokea
The nurse is caring for a client who has just received a diagnosis of terminal cancer. The client says, 'I don't want to tell my family yet.' Which of the following responses by the nurse is most appropriate?
- A. You should tell them soon so they can support you.'
- B. I respect your decision. Let me know how I can help you.'
- C. Your family needs to know so they can prepare.'
- D. I'll talk to your family for you if you'd like.'
Correct Answer: B
Rationale: Respecting the client's autonomy while offering support is the most appropriate response, honoring their decision about disclosure.
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A 10-month-old child has cold symptoms. The mother asks how she can clear the infant's nose. Which of the following would be the nurse's best recommendation?
- A. Use a cool air vaporizer with plain water.
- B. Use saline nose drops and then a bulb syringe.
- C. Blow into the child's mouth to clear the infant's nose.
- D. Administer a nonprescription vasoconstrictive nose spray.
Correct Answer: B
Rationale: Saline nose drops followed by bulb syringe suction is safe and effective for clearing nasal congestion in infants. Vaporizers help with humidity, but saline and suction directly clear the nose.
A family member asks to take the client, who is on aneurysm precautions, to the unit lounge for 'just a few minutes.' Which concepts should the nurse use when explaining why the client must remain in the room?
- A. A quiet environment promotes more rapid healing of the aneurysm.
- B. Clients with aneurysms need isolation to cope with photosensitivity.
- C. Reduced environmental stimuli are needed to prevent aneurysm rupture.
- D. The client has disorganization of thoughts and feelings and needs reduced activity.
Correct Answer: C
Rationale: Subarachnoid precautions (or aneurysm precautions) are intended to minimize environmental stimuli, which could increase intracranial pressure and trigger bleeding or rupture of the aneurysm. The aneurysm will not heal more rapidly with reduced stimuli. The client does not need isolation to 'cope' with photosensitivity (although photosensitivity may be a problem). No data indicate that the client has disorganization of thoughts and feelings.
A 6-year-old child is admitted with suspected appendicitis. Which symptom should the nurse prioritize when assessing this child?
- A. Fever
- B. Nausea
- C. Rebound tenderness
- D. Diarrhea
Correct Answer: C
Rationale: Rebound tenderness in the right lower quadrant is a hallmark sign of appendicitis, indicating peritoneal irritation and requiring urgent surgical evaluation.
A client with chronic obstructive pulmonary disease is bedridden at home and gets little exercise. The nurse should assess the client for which of the following?
- A. Increased sodium retention.
- B. Increased calcium excretion.
- C. Increased insulin use.
- D. Increased red blood cell production.
Correct Answer: B
Rationale: Prolonged immobility in COPD increases calcium excretion due to bone resorption, risking osteoporosis. The other options are not directly related to immobility.
The nurse is assigned to care for a client with a chest tube attached to closed chest drainage. Which assessment data should the nurse identify as an indicator that the client's lung has completely expanded?
- A. Pleuritic chest pain has resolved.
- B. The oxygen saturation is greater than 92%.
- C. Fluctuations in the water-seal chamber ceased.
- D. Suction in the chest drainage system is no longer needed.
Correct Answer: C
Rationale: When the lung has completely expanded, there is no longer air in the pleural space causing fluctuations in the water-seal chamber. Thus, an indication that a chest tube is ready for removal is when fluctuations in the water-seal chamber cease. Although air is known to be an irritant to pleural tissue, cessation of pleuritic pain does not indicate that the lung is expanded. The chest tube acts as an irritant and therefore contributes to pain. Adequate oxygen saturation does not imply that the lung has fully reexpanded. Use or nonuse of suction in the chest drainage system is not necessarily governed by the degree of lung expansion. Suction is indicated when gravity is not sufficient to drain air and pleural fluid or if the client has a poor respiratory effort and cough.