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The nurse is caring for a client with a history of depression who is receiving fluoxetine (Prozac) 20 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have a dry mouth.
- C. I think about ending my life.
- D. I take my medication with food.
Correct Answer: C
Rationale: Thoughts of ending life indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on fluoxetine. Options A, B, and D are less concerning: fatigue and dry mouth are common side effects, and taking with food is acceptable.
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The nurse is caring for a client who is postoperative day 2 after a bowel resection. Which of the following findings would be of GREATest concern to the nurse?
- A. Absence of bowel sounds.
- B. Temperature of 99.8°F (37.7°C).
- C. Pain at the incision site.
- D. Urine output of 30 mL/hour.
Correct Answer: A
Rationale: Absence of bowel sounds on postoperative day 2 may indicate paralytic ileus or obstruction, a serious complication requiring immediate evaluation. Options B, C, and D are expected or normal: slight fever is common, incision pain is typical, and urine output is adequate.
Which of the following assessments would be a priority when documenting the nursing history of a two-year-old child?
- A. The child's rituals and routines at home.
- B. The child's understanding of hospitalization.
- C. The child's ability to be separated from the parents.
- D. The parent's methods for dealing with the child's temper tantrums.
Correct Answer: A
Rationale: during a crisis such as hospitalization, children are able to establish a sense of security through consistency of the rituals and routines from home
The nurse is teaching a client with newly diagnosed diabetes mellitus how to treat hypoglycemia at home. The nurse should instruct the client to do which of the following actions if symptoms of hypoglycemia are experienced?
- A. Eat a candy bar.
- B. Drink ½-cup fruit juice followed by a protein snack.
- C. Inject 10 units of Humulin R.
- D. Inject glucagon.
Correct Answer: B
Rationale: will correct hypoglycemia and stabilize blood sugar
The nurse is caring for a client with a history of congestive heart failure (CHF). Which of the following findings would indicate to the nurse that the client's condition is worsening?
- A. Clear lung sounds bilaterally.
- B. Weight gain of 2 pounds in 24 hours.
- C. Urine output of 1,200 mL in 24 hours.
- D. Heart rate of 88 beats per minute.
Correct Answer: B
Rationale: weight gain is a sign of fluid retention, indicating worsening CHF
Which of the following strategies would be MOST therapeutic as the nurse tries to analyze a bulimic client's eating habits and the circumstances that precipitate the client's eating problems?
- A. Observe family communication patterns at a 'monitored mealtime.'
- B. Distract the client at mealtime.
- C. Assign the client a food/feelings/thoughts/actions journal.
- D. Assign the client to write a 'lifeline' in relation to eating behaviors.
Correct Answer: C
Rationale: implementation, nurse is trying to analyze and understand what triggers the client's binging and purging activities, so therapeutic nursing intervention of assigning a thought/feelings/actions (T/F/A) journal relating to client's eating behaviors will be most helpful to the nurse and therapeutic to the client; after this information is gained and reviewed, collaboration by the nurse and client on other strategies such as delay and distraction techniques, stress reduction, and developing a 'lifeline' in relation to eating behaviors will further benefit the client