Nokea
The nurse is caring for a client with benign prostatic hypertrophy. Which of the following assessments would the nurse anticipate finding?
- A. Large volume of urinary output with each voiding.
- B. Involuntary voiding with coughing and sneezing.
- C. Frequent urination.
- D. Urine is dark and concentrated.
Correct Answer: C
Rationale: Frequent urination is common due to urethral obstruction.
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Which of the following would indicate that Mrs. Filbert understands what you have taught her about her condition?
- A. She delays asking for medication so that she will not become addicted
- B. She asks for medication upon the first indication of an attack
- C. She permits the nurse to perform all of her morning care
- D. She asks her family to assist her at mealtime
Correct Answer: B
Rationale: Promptly seeking medication at the onset of symptoms reflects understanding of how to manage acute attacks effectively.
Which action best demonstrates respect for autonomy when working with a client?
- A. Asks if the client has questions before signing a consent form
- B. Provides the client with accurate information when questioned
- C. Honors the promises made to the client and family
- D. Ensures fair treatment of the client compared to others
Correct Answer: A
Rationale: The correct answer is A because asking if the client has questions before signing a consent form shows respect for autonomy by allowing the client to make an informed decision. This action promotes the client's right to self-determination and involvement in the decision-making process. Choice B focuses on providing information when questioned but may not actively involve the client in the decision-making process. Choice C refers to honoring promises and not necessarily respecting autonomy. Choice D relates to fairness but does not directly address autonomy or the client's decision-making ability.
You are reviewing the drug list of an elderly client who is on several medications prescribed by different specialists for various health problems. The client reports 'lately there has been a roaring sound in my ears.' You notify the prescriber of which medication?
- A. gentamicin sulfate (Garamycin)
- B. metoprolol (Lopressor)
- C. amoxicillin (Amoxil)
- D. warfarin (Coumadin)
Correct Answer: A
Rationale: Gentamicin is an ototoxic medication that can cause tinnitus or hearing loss, warranting notification of the prescriber.
When assessing a skin lesion, you look for A-asymmetry, B-irregular borders, C-variegated colors, D-diameter, and E-
- A. Edema.
- B. Erythema.
- C. Elevation.
- D. Ever-changing.
Correct Answer: C
Rationale: Elevation is one of the ABCDE criteria for assessing suspicious skin lesions.
When orienting a new client and family to the inpatient unit, what information should the nurse provide to help the client promote their own safety?
- A. Encourage the client and family to be active partners.
- B. Instruct the client to monitor hand hygiene in caregivers.
- C. Offer the family the opportunity to stay with the client.
- D. Advise the client to always wear their armband.
Correct Answer: A
Rationale: Step 1: Encouraging the client and family to be active partners promotes safety by involving them in care decisions.
Step 2: This empowers the client to voice concerns and preferences, enhancing their safety.
Step 3: Monitoring hand hygiene (B) is important but doesn't directly involve the client's active participation.
Step 4: Offering family to stay (C) is supportive but doesn't directly engage the client in promoting their own safety.
Step 5: Advising to wear armband (D) is a procedural measure, not a collaborative safety-promoting action.