Nokea
The nurse is collecting data on a client with hypertension and essential tremor who received the first dose of propranolol 2 hours ago. Which assessment is most concerning to the nurse?
- A. Client reports a headache
- B. Current blood pressure is 160/88 mm Hg
- C. Heart rate has decreased from 70/min to 60/min
- D. Slight wheezes auscultated during inspiration
Correct Answer: D
Rationale: Wheezing post-propranolol is concerning for bronchospasm, a serious side effect in a patient with no known respiratory history. Headache , elevated BP , and mild heart rate decrease are less urgent.
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Four clients arrive in the urgent care clinic. Which does the nurse anticipate to be the priority for intervention?
- A. Child who is confused and irritable and whose parent claims 2 glyburide pills are missing
- B. Child with an abscess on the buttock that is red, swollen, and warm to the touch
- C. Child with immune thrombocytopenia who fell off a bike and reports shoulder pain
- D. Child with low-grade fever, barking cough, and runny nose who has mild retractions
Correct Answer: A
Rationale: The child who is confused and irritable with missing glyburide pills suggests a potential hypoglycemic emergency due to sulfonylurea overdose, which requires immediate intervention to prevent severe complications like seizures or coma.
The nurse has attended a staff education program about narcissistic personality disorder (NPD). The nurse should understand that clients with NPD
- A. experience a fear of abandonment and have a fragile self-esteem
- B. may require medication to manage hallucinations
- C. demonstrate magical thinking and feelings of depersonalization
- D. experience episodes of acute anxiety
Correct Answer: A
Rationale: Clients with NPD typically have a fragile self-esteem masked by grandiosity and may fear abandonment . Hallucinations are not characteristic, magical thinking aligns more with schizotypal personality disorder, and acute anxiety is less specific.
A woman is being seen in the physician's office for a medical complaint. When she is called to see the physician, she goes to the restroom and washes her hands over and over, missing her allotted time with the physician. How should the nurse deal with this woman?
- A. Send her home without seeing the doctor if she is not available when called
- B. Give her advance warning that she will be seeing the physician and tell her that if she needs to wash her hands, she should do so
- C. Interrupt her washing ritual and insist that she see the physician when it is her turn
- D. Give her a choice of seeing the physician or washing her hands
Correct Answer: B
Rationale: Advance warning accommodates possible OCD, allowing hand washing within a timeframe, ensuring she sees the physician. Sending home, interrupting, or forcing choices is less effective.
An adult who had a laryngectomy is ready for discharge. What question is it essential for the nurse to ask the client before discharge?
- A. How many people live in your household?
- B. Does your home have working smoke detectors?
- C. Do you cook with gas or electricity?
- D. When is your doctor's appointment?
Correct Answer: B
Rationale: Smoke detectors are critical post-laryngectomy, as impaired speech and potential airway issues increase fire safety risks, making this a priority discharge question.
The nurse begins to assist with ambulation of a 9-year-old client who is 1 day postoperative appendectomy when the child cries out, 'It hurts too much. I can't do it.' Which action should the nurse complete first?
- A. Administer a PRN analgesic and monitor for adverse effects
- B. Ask the client to point to a numeric scale to indicate pain level
- C. Come back later in the day to attempt ambulation again
- D. Encourage the client to walk to promote blood circulation
Correct Answer: B
Rationale: Assessing pain level using a numeric scale is the first step to quantify the child's pain and determine the need for analgesics or other interventions. Administering analgesics without assessment is premature, delaying ambulation avoids addressing pain, and encouraging walking ignores the child's distress.