Nokea
The nurse is caring for a client with a suspected stroke. Which assessment should the nurse perform first?
- A. Check blood glucose levels
- B. Assess pupil response
- C. Evaluate speech and motor function
- D. Monitor blood pressure
Correct Answer: C
Rationale: Evaluating speech and motor function first helps confirm stroke symptoms using tools like the FAST scale, guiding urgent intervention.
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Sulfadiazine has been ordered for a client who has a urinary tract infection. Which of the following recommend is most appropriate for administering sulfonamides?
- A. Encourage the client to take the medication with meals.
- B. Instruct the client to drink at least 8 glasses of water a day.
- C. Measure the client's urine output.
- D. Instruct the client that the urine may turn reddish orange.
Correct Answer: B
Rationale: Adequate hydration (8 glasses of water daily) prevents crystalluria, a complication of sulfonamides.
To prevent development of peripheral neuropathies associated with isoniazid administration, the nurse should teach the client to:
- A. Avoid excessive sun exposure.
- B. Follow a low-cholesterol diet.
- C. Obtain extra rest.
- D. Supplement the diet with pyridoxine (vitamin B6).
Correct Answer: D
Rationale: Isoniazid can deplete vitamin B6, leading to neuropathy; supplementation prevents this side effect.
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.
A 13-year-old client is dying of cancer and struggling with the emotional aspects of this. When providing care for this client, the nurse should incorporate the developmental tasks for this age. According to Erikson's developmental model, the child normally is expected to be working on which of the following psychosocial issues?
- A. Identity vs. role confusion.
- B. Intimacy vs. isolation.
- C. Industry vs. inferiority.
- D. Autonomy vs. shame and doubt.
Correct Answer: A
Rationale: Adolescents (ages 12–18) focus on identity vs. role confusion, developing a sense of self and personal identity.
The nurse is delivering care to a client who is diagnosed with toxic shock syndrome (TSS). Which complication of this syndrome should the nurse monitor the client for?
- A. Pulmonary embolism
- B. Vitamin K deficiency
- C. Factor VIII deficiency
- D. Disseminated intravascular coagulopathy (DIC)
Correct Answer: D
Rationale: TSS is caused by infection and is often associated with tampon use. DIC is a complication of TSS. The nurse monitors the client for signs of this complication, and notifies the primary health care provider promptly if signs and symptoms are noted. The other options are not complications of TSS.