Nokea
The nurse is caring for a client with social anxiety disorder. Which of the following situations would most likely exacerbate the client's symptoms?
- A. Shopping in a crowded grocery store
- B. Moving into a new home with the spouse
- C. Speaking in front of peers at a professional convention
- D. Attending an appointment with a new health care provider
Correct Answer: C
Rationale: Speaking publicly, especially to peers, is highly likely to trigger social anxiety due to fear of scrutiny. Crowded stores, moving, and new providers may cause anxiety but are less intense triggers.
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The nurse is assessing a child for clinical manifestations of iron deficiency anemia. Which factor would the nurse recognize as the cause of the findings?
- A. Decreased cardiac output
- B. Tissue hypoxia
- C. Cerebral edema
- D. Reduced oxygen saturation
Correct Answer: B
Rationale: Tissue hypoxia. Iron deficiency anemia reduces oxygen-carrying capacity, causing tissue hypoxia.
The nurse is reinforcing discharge teaching for a client who had aortic valve replacement with a mechanical heart valve. Which statement by the client indicates that teaching has been effective?
- A. I'm glad that I can continue taking my Ginkgo biloba.
- B. I will increase my intake of leafy green vegetables
- C. I will start applying vitamin E to my chest incision after showering
- D. I will shave with an electric razor from now on
Correct Answer: D
Rationale: Mechanical prosthetic valves are more durable than biological valves but require long-term anticoagulation therapy due to the increased risk of thromboembolism. The client should be taught ways to reduce the risk of bleeding.
The nurse is reinforcing teaching with a client who has a new prescription for transdermal nitroglycerin patches for angina. Which of the following statements by the client would require follow-up?
- A. I can apply a new patch to my arm or chest each day
- B. I should avoid placing the patch over areas with a lot of hair
- C. I should remove the patch at night to prevent tolerance
- D. I will apply the patch only when I experience chest pain
Correct Answer: D
Rationale: Nitroglycerin patches are for angina prevention, applied daily, not as-needed. Rotating sites, avoiding hair, and removing at night (patch-free interval) are correct.
What should the nurse do when ambulating a client who has a portable wound drainage system?
- A. Remove the drainage catheter during ambulation
- B. Fasten the collection device below the wound
- C. Completely empty the collection device before ambulating
- D. Disconnect the suction apparatus from the client before ambulating
Correct Answer: B
Rationale: Fastening the drainage device below the wound promotes gravity-dependent drainage, preventing reflux and infection during ambulation.
An elderly war veteran with prostate cancer and coronary artery disease is hospitalized for urosepsis. The client becomes angry with one of the unlicensed assistive personnel (UAP) who is trying to help the client bathe. Later, the UAP expresses frustration with the client to the nurse. Which statement would be the most appropriate response?
- A. I’ll talk with the client to see why the client is angry
- B. It sounds like you shouldn’t work with this client, so I will reassign you
- C. Let’s go together to ask about the client’s concerns
- D. Why don’t you go talk with the client about why the client is angry?
Correct Answer: C
Rationale: Going together to address concerns promotes teamwork, de-escalates conflict, and ensures the client’s needs are met. Individual talks risk miscommunication, and reassignment avoids resolution.