Nokea
The nurse is caring for a client with schizophrenia who is experiencing auditory hallucinations and has a new prescription for an oral antipsychotic. Which of the following actions should the nurse take?
- A. Provide music for the client
- B. Use gentle touch to calm the client
- C. Instruct the client to ignore the hallucinations
- D. Tell the client the medication will alleviate the hallucinations within a few hours
Correct Answer: C
Rationale: Instructing the client to ignore hallucinations helps them manage symptoms by redirecting focus, a practical coping strategy. Music or touch may exacerbate distress, and antipsychotics typically take days to weeks to reduce hallucinations, not hours.
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A nurse auscultates a loud cardiac murmur on a newborn with suspected trisomy 21 (Down syndrome). A genetic screen and an echocardiogram are scheduled that day. The neonate’s vital signs are shown in the exhibit. What would be an appropriate action for the nurse to complete next?
- A. Call the health care provider immediately
- B. Document the finding
- C. Place the neonate in a knee-chest position
- D. Provide oxygen to the neonate
Correct Answer: B
Rationale: Documenting the murmur is appropriate as genetic screening and an echocardiogram are already scheduled, indicating the provider is aware. Calling the provider is unnecessary, knee-chest position is for specific heart defects, and oxygen is not indicated without respiratory distress.
The nurse is teaching a client with metastatic bone disease about measures to prevent hypercalcemia. It would be important for the nurse to emphasize
- A. The need for at least 5 servings of dairy products daily
- B. Restriction of fluid intake to less than 1 liter per day
- C. The importance of walking as much as possible
- D. The use of sunscreen to prevent skin damage
Correct Answer: C
Rationale: The importance of walking as much as possible. Mobility prevents bone demineralization, reducing the risk of hypercalcemia.
The nurse is preparing to administer an acetaminophen suppository to a 4-year-old client. Which of the following actions should the nurse take? Select all that apply.
- A. Place the client in the side-lying position.
- B. Guide the suppository along the rectal wall.
- C. Use a gloved index finger to insert the suppository.
- D. Advance the suppository no further than the external sphincter.
- E. Hold the client's buttocks together firmly after inserting the suppository.
Correct Answer: A,C,E
Rationale: The side-lying position facilitates insertion, a gloved finger ensures hygiene, and holding buttocks prevents expulsion. Guiding along the rectal wall is unnecessary, and the suppository should be inserted beyond the external sphincter for absorption.
Which information should be included in the nurse's shift report?
- A. The client's sodium level is 147 mEq/L
- B. The client's potassium level is 4 mEq/liter
- C. The client's urine output was 1500 cc in 5 hours
- D. The client is to receive another dose of Lasix at 10 PM
Correct Answer: C
Rationale: Although all of these may be correct information to include in report, the essential piece would be the urine output, as it indicates the client's fluid status and response to treatment.
The nurse is caring for assigned clients. The nurse should recognize the client at highest risk for developing a pulmonary embolism is the client who
- A. has pneumonia
- B. has a subdural hematoma
- C. had a cesarean birth 6 hours ago
- D. is receiving hormone replacement therapy
Correct Answer: C
Rationale: Recent cesarean birth increases pulmonary embolism risk due to immobility, surgical trauma, and hypercoagulability postpartum. Pneumonia, subdural hematoma, and hormone therapy carry lower or less immediate risks in this context.