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The nurse is caring for a client who received albuterol 30 minutes ago for an acute exacerbation of asthma. It would indicate that the medication has been effective if the client experiences a decreased
- A. Use of accessory muscles
- B. Blood pressure
- C. Level of anxiety
- D. Heart rate
Correct Answer: A
Rationale: Albuterol, a bronchodilator, relieves bronchospasm in asthma, reducing airway resistance. Decreased use of accessory muscles (A) indicates improved breathing and oxygenation, a direct sign of albuterol's effectiveness. Changes in blood pressure (B), anxiety (C), or heart rate (D) are not primary indicators of albuterol's effect, as they may be influenced by other factors like the stress of the attack or concurrent medications.
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An adult who has cholecystitis reports clay-colored stools and moderate jaundice. The nurse knows that which is the best explanation for the presence of clay-colored stools and jaundice?
- A. There is an obstruction in the pancreatic duct.
- B. There are gallstones in the gallbladder.
- C. Bile is no longer produced by the gallbladder.
- D. There is an obstruction in the common bile duct.
Correct Answer: D
Rationale: Clay-colored stools and jaundice result from a common bile duct obstruction, preventing bile flow to the intestines and causing bilirubin buildup in the blood. The gallbladder stores, not produces, bile, and pancreatic or gallbladder issues are less directly related.
During an initial prenatal visit, the practical nurse is reviewing the history of a client at 10 weeks gestation. Which finding is a priority to report to the registered nurse?
- A. Client cares for a pet dog and a few outdoor cats
- B. Client has gained 4 lb (1.8 kg) during the pregnancy so far
- C. Client reports a nonodorous, milky white vaginal discharge
- D. Client swims in a pool for exercise three times per week
Correct Answer: A
Rationale: Pet cats (A) pose a toxoplasmosis risk, which can cause fetal harm, requiring immediate education and possible testing. Weight gain (B) is normal, milky discharge (C) is typical in pregnancy, and swimming (D) is safe.
The nurse is caring for a client with schizophrenia who is experiencing visual hallucinations. The client states, 'There is a bad person standing in my room.' Which of the following responses would be most appropriate for the nurse to make?
- A. Your illness is making you experience visual hallucinations.'
- B. I know you are frightened, but I do not see anyone in your room.'
- C. Do not worry. I will give you medication that will make the bad person go away.'
- D. We will go into the dayroom and play a game. I know you like to play board games.'
Correct Answer: B
Rationale: When addressing hallucinations, the nurse should acknowledge the client’s fear while gently reinforcing reality. Response B validates the client’s emotions and clarifies that the nurse does not see the hallucination, maintaining trust without reinforcing the delusion. Labeling the hallucination as part of the illness (A) may confuse or alienate the client. Promising medication will resolve it (C) oversimplifies treatment, and distracting with games (D) dismisses the client’s distress.
The nurse on the mental health unit is talking with a client with schizophrenia. Which of the following statements by the client would indicate that the client is experiencing a delusion of reference?
- A. Did you hear that voice? It told me to kill my parent.
- B. I need to get rid of the bugs that are crawling under my skin.
- C. The song on the radio is a message sent to me in secret code.
- D. I will not drink the tap water. The aliens are trying to poison me.
Correct Answer: C
Rationale: A delusion of reference involves believing neutral events or objects (e.g., a song on the radio) have personal significance or hidden messages (C). Auditory hallucinations (A) involve hearing voices, not reference. Tactile hallucinations (B) involve false sensations, and persecutory delusions (D) involve belief in harm without reference to neutral stimuli.
The emergency room nurse admits a child who experienced a seizure at school. The parent comments that this is the first occurrence and denies any family history of epilepsy. What is the best response by the nurse?
- A. Do not worry. Epilepsy can be treated with medications.
- B. The seizure may or may not mean your child has epilepsy.
- C. Since this was the first convulsion, it may not happen again.
- D. Long term treatment will prevent future seizures.
Correct Answer: B
Rationale: The seizure may or may not mean your child has epilepsy. A single seizure has multiple potential causes, not necessarily epilepsy.