Nokea
The nurse is caring for a client who will not use the train for transportation due to the fear of being trapped and unable to escape. The nurse should recognize that the client is likely experiencing
- A. generalized anxiety disorder
- B. social anxiety disorder
- C. agoraphobia
- D. acrophobia
Correct Answer: C
Rationale: Fear of being trapped in situations (e.g., trains) with no escape is characteristic of agoraphobia. Generalized anxiety involves broad worries, social anxiety focuses on social scrutiny, and acrophobia is fear of heights.
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The nurse is reinforcing discharge teaching on a client with polycythemia vera. Which would be included in the teaching plan?
- A. Avoid large crowds.
- B. Keep the head of the bed elevated at night.
- C. Wear socks and gloves when going outside.
- D. Know the signs and symptoms of thrombosis.
Correct Answer: D
Rationale: Polycythemia vera increases blood viscosity, raising the risk of thrombosis. Teaching the client to recognize signs and symptoms of thrombosis, such as swelling or pain in extremities, is critical. Avoiding large crowds relates to infection risk, not thrombosis. Elevating the head of the bed is unrelated, and wearing socks and gloves is more relevant for conditions like Raynaud's.
The nurse is caring for a client who had a total thyroidectomy. What should the nurse plan to observe the client for immediately after his return to the nursing care unit?
- A. Hoarseness
- B. Signs of hypercalcemia
- C. Loss of reflexes
- D. Mental confusion
Correct Answer: B
Rationale: Total thyroidectomy risks parathyroid gland damage, leading to hypocalcemia (not hypercalcemia). However, the question likely intends hypocalcemia signs (tetany, spasms), which are critical to monitor immediately post-surgery. Hoarseness, reflexes, or confusion are less urgent.
Following change-of-shift report on an orthopedic unit, which client should the nurse see first?
- A. 16 year-old who had an open reduction of a fractured wrist 10 hours ago
- B. 20 year-old in skeletal traction for 2 weeks since a motor cycle accident
- C. 72 year-old recovering from surgery after a hip replacement 2 hours ago
- D. 75 year-old who is in skin traction prior to planned hip pinning surgery.
Correct Answer: C
Rationale: Look for the client who has the most imminent risks and acute vulnerability. The client who returned from surgery 2 hours ago is at risk for life threatening hemorrhage and should be seen first.
Laboratory results
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L)
180 mg/dL
(10.0 mmol/L)
The nurse is preparing to administer insulin aspart subcutaneously at 0700 to a client with type 1 diabetes mellitus. Which of following actions would be a priority for the nurse to take?
- A. Choose a site on the clients arm for the injection
- B. Give the client breakfast within 15 minutes
- C. Recheck the capillary blood glucose level in 1 hour
- D. Reinforce teaching about signs and symptoms of hyperglycemia
Correct Answer: B
Rationale: Insulin aspart is rapid-acting, peaking within 1-3 hours. Administering it at 0700 requires breakfast within 15 minutes to prevent hypoglycemia. Site selection is routine, rechecking glucose later is secondary, and teaching is not urgent.
The nurse is reviewing discharge instructions with a client going home on linezolid therapy for a vancomycin-resistant enterococcus infection. Which client statement requires further teaching?
- A. I can restart my paroxetine once I get back home.
- B. I can take acetaminophen for headaches.
- C. I will avoid foods and drinks that contain tyramine.
- D. I will report any increased fever or diarrhea.
Correct Answer: A
Rationale: Linezolid interacts with SSRIs like paroxetine, risking serotonin syndrome, requiring a washout period. Acetaminophen is safe, tyramine avoidance prevents hypertensive crises, and reporting fever/diarrhea monitors treatment response.