Nokea
The nurse is caring for a client with liver cirrhosis. Which of the following assessment findings would warrant immediate follow up?
- A. Black, tarry stool
- B. Bright red-streaked stool
- C. Light gray clay-colored stool
- D. Small, dry, rocky stool
Correct Answer: A
Rationale: Black, tarry stool (melena) indicates upper gastrointestinal bleeding, a serious complication in cirrhosis due to portal hypertension or varices, requiring immediate intervention.
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Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students?
- A. Scratching the head more than usual
- B. Flakes evident on a student's shoulders
- C. Oval pattern occipital hair loss
- D. Whitish oval specks sticking to the hair
Correct Answer: D
Rationale: Diagnosis of pediculosis capitis is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment can include application of a medicated shampoo with lindane for children over 2 years of age, and meticulous combing and removal of all nits.
A 16 month-old child has just been admitted to the hospital. As the nurse assigned to this child enters the hospital room for the first time, the toddler runs to the mother, clings to her and begins to cry. What would be the initial action by the nurse?
- A. Arrange to change client care assignments
- B. Explain that this behavior is expected
- C. Discuss the appropriate use of time-out
- D. Explain that the child needs extra attention
Correct Answer: B
Rationale: Explain that this behavior is expected. Fear of strangers is normal in toddlers and extends into the preschool period.
When unlicensed assistive personnel (UAP) assist a client with a chest tube back to bed from the bedside commode, the plastic chest drainage unit accidentally falls over and cracks. The UAP immediately report this incident to the nurse. What is the nurse's immediate action?
- A. Clamp the tube close to the client's chest until a new chest drainage unit is set up
- B. Notify the health care provider
- C. Place the distal end of the chest tube into a bottle of sterile saline
- D. Position the client on the left side
Correct Answer: C
Rationale: Placing the distal end of the chest tube in sterile saline maintains a water seal, preventing air from entering the pleural space until a new drainage unit is prepared.
Laboratory results
Glucose (random)
71-200 mg/dL
(3.9–11.1 mmol/L) 58 mg/dL
(3.2 mmol/L)
The nurse is caring for a client with type 2 diabetes mellitus who reports feeling lightheaded and shaky. Which of the following actions should the nurse take next?
- A. Administer glucagon by subcutaneous injection as prescribed
- B. Administer rapid-acting insulin per sliding scale as prescribed
- C. Give the client 4 oz (120 mL) of fruit juice or a regular soft drink
- D. Give the client a snack of cheese or peanut butter with crackers
Correct Answer: C
Rationale: Lightheadedness and shakiness suggest hypoglycemia. Providing 15 grams of fast-acting carbohydrates, such as 4 oz of fruit juice, is the first-line treatment to raise blood glucose levels quickly.
The nurse in the outpatient clinic is talking with the spouse of a client with borderline personality disorder. The client's spouse states, 'My spouse self-inflicts lacerations on the arms to stop me from traveling for business. My spouse's actions are not a serious attempt at self-harm.' Which of the following responses would be appropriate for the nurse to make?
- A. You should cancel your upcoming business trip.
- B. Your spouse should come to the clinic today to be assessed.
- C. It sounds like you are having a difficult time coping with your spouse's behavior.
- D. It is best to ignore your spouse's behavior because your spouse is doing this to gain attention.
Correct Answer: B
Rationale: Self-inflicted lacerations, even if not suicidal, indicate significant distress in borderline personality disorder and require professional assessment to ensure safety and address underlying issues.