Nokea
The nurse is caring for a client with a diagnosis of major depressive disorder. Which of the following client statements would indicate that the client is responding positively to the prescribed antidepressant therapy?
- A. I feel like my energy level is starting to improve.
- B. I still don’t enjoy doing things I used to love.
- C. I have trouble sleeping through the night.
- D. I feel worthless and don’t want to see anyone.
Correct Answer: A
Rationale: improved energy level is a positive sign of response to antidepressant therapy
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A client with hepatitis C is scheduled for a liver biopsy. Which would the nurse include in the teaching plan?
- A. The client should lie on the left side after the procedure.
- B. Cleansing enemas should be given the morning of the procedure.
- C. Blood coagulation studies might be done before the biopsy.
- D. The procedure is noninvasive and causes no pain.
Correct Answer: C
Rationale: Hepatitis C increases bleeding risk, so coagulation studies are done before a liver biopsy to ensure safety. The client lies on the right side post-procedure, enemas aren't needed, and the procedure is invasive with some pain.
A client in the cardiac step-down unit requires suctioning for excess mucous secretions. The dysrhythmia most commonly seen during suctioning is:
- A. Bradycardia
- B. Tachycardia
- C. Premature ventricular beats
- D. Heart block
Correct Answer: A
Rationale: Suctioning can stimulate the vagus nerve, leading to bradycardia due to parasympathetic activation.
The nurse has documented a treatment on the wrong client's record. Which of the following methods of indicating the error is correct?
- A. The nurse draws a straight line through the incorrect entry and writes 'error' above it and initials the correction.
- B. The nurse uses correction fluid to cover the incorrect entry.
- C. The nurse draws multiple lines through the incorrect entry so it is unreadable, writes 'error' above it, and initials the correction.
- D. The nurse leaves the incorrect entry in place, writes 'error' in the margin, and initials and dates the notation.
Correct Answer: A
Rationale: A single line through the error with 'error' written above and initialed (A) maintains transparency while correcting the record. Correction fluid (B) is unacceptable, multiple lines (C) obscure the record, and margin notes (D) are insufficient.
The nurse working in an outpatient pain clinic has the opportunity to teach a client with chronic back pain about nonpharmacological pain management. Which of the following would be most appropriate for the nurse to include when teaching? Select all that apply.
- A. music
- B. therapeutic massage
- C. stretching exercises
- D. relaxation
Correct Answer: A, B, C, D
Rationale: Music, therapeutic massage, stretching exercises, and relaxation are all evidence-based nonpharmacological methods to manage chronic pain.
The nurse is suspected of charting medication administration that he did not give. The nurse can be charged with:
- A. Fraud
- B. Malpractice
- C. Negligence
- D. Tort
Correct Answer: A
Rationale: Falsifying medical records, such as charting unadministered medications, constitutes fraud.