Nokea
The nurse is discussing hypertension with a group of people. Which person is at greatest risk for hypertension?
- A. A 63-year-old overweight Caucasian female office worker who smokes and whose parents both had high blood pressure.
- B. A 52-year-old African-American female of normal weight whose parents have diabetes and who is an avid swimmer.
- C. A 48-year-old Hispanic-American smoker whose father had high blood pressure.
- D. A 45-year-old Native American who leads a sedentary life and smokes.
Correct Answer: A
Rationale: Age, obesity, smoking, and family history of hypertension confer the highest risk, as seen in the 63-year-old Caucasian female.
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A client with cancer tells the nurse that he would like to make out a living will. The nurse knows that a living will provides documentation of:
- A. The client's desire to receive all means of assistance to sustain life.
- B. The client's desire to allow another to make decisions regarding his care.
- C. The client's wish to die without life-prolonging interventions.
- D. The client's desire to have his life terminated by active euthanasia.
Correct Answer: C
Rationale: A living will documents a client's wish to avoid life-prolonging interventions in terminal conditions. It does not mandate all assistance, delegate decisions, or support euthanasia.
The nurse is reinforcing teaching on oral care and symptom management to a client with head and neck cancer who has developed mouth sores related to external radiation therapy. Which of the following instructions should the nurse include? Select all that apply.
- A. Apply a water-soluble lubricating agent to moisturize mouth tissue
- B. Avoid hot liquids and foods that are spicy or acidic
- C. Brush your teeth with a soft-bristle toothbrush
- D. Cleanse the mouth with saline after meals and at bedtime
- E. Rinse with alcohol-based antiseptic mouthwash to decrease mouth odor
Correct Answer: A,B,C,D
Rationale: Water-soluble lubricant , avoiding irritants , soft brushing , and saline rinses promote comfort. Alcohol-based mouthwash irritates sores.
A new nurse manager is seeking a mentor in the administrative realm. Which of these characteristics is a priority for the outcome of a positive experience with a mentor?
- A. Information is clarified as needed
- B. A teacher-coach role is taken by the mentor
- C. The mentee accepts feedback objectively
- D. The mentor is randomly assigned by administration
Correct Answer: B
Rationale: A teacher-coach role is taken by the mentor. A mentor who guides and coaches fosters a productive learning experience.
At the geriatric day care program a client is crying and repeating 'I want to go home. Call my daddy to come for me.' The nurse should
- A. Inform the client that she must wait until the program ends at 5:00 pm to leave
- B. Give the client simple information about what she will be doing
- C. Tell the client you will call someone to come for her and suggest joining the exercise group while she waits
- D. Firmly direct the client to her assigned group activity
Correct Answer: C
Rationale: Tell the client you will call someone to come for her and suggest joining the exercise group while she waits. This uses comforting and distraction to reduce distress in dementia.
The nurse in the emergency department is caring for a client who has a small piece of wood penetrating the right eye. Which of the following actions should the nurse take?
- A. Flush the eye
- B. Remove the object with tweezers.
- C. Stabilize the object.
- D. Administer optic antibiotic ointment.
Correct Answer: C
Rationale: Stabilizing the object prevents further damage until surgical removal. Flushing , removing , or applying ointment risks worsening the injury.