Nokea
The nurse is discussing psychosocial implications of Huntington's chorea with the adult child of a client diagnosed with the disease. Which psychosocial intervention should the nurse implement?
- A. Refer the child for genetic counseling as soon as possible.
- B. Teach the child to use a warming tray under the food during meals.
- C. Discuss the importance of not abandoning the parent.
- D. Allow the child to talk about the fear of getting the disease.
Correct Answer: D
Rationale: Huntington’s has a 50% genetic risk. Allowing the child to express fears (D) addresses psychosocial needs therapeutically. Genetic counseling (A) is appropriate but secondary, warming trays (B) are irrelevant, and abandonment discussions (C) may guilt-trip.
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The husband of a client who is an alcoholic tells the nurse, 'I don’t know what to do. I don’t know how to deal with my wife’s problem.' Which response would be most appropriate by the nurse?
- A. It must be difficult. Maybe you should think about leaving.'
- B. I think you should attend Alcoholics Anonymous.'
- C. I think that Alanon might be very helpful for you.'
- D. You should not enable your wife’s alcoholism.'
Correct Answer: C
Rationale: Alanon (C) supports families of alcoholics, offering coping strategies. Suggesting leaving (A) is judgmental, AA (B) is for alcoholics, and accusing enabling (D) may alienate.
When documenting a seizure, which information is most important to include initially?
- A. The time the seizure started
- B. The duration of the seizure
- C. The client's mood just before the seizure
- D. The client's comments after the seizure
Correct Answer: A
Rationale: Documenting the time the seizure started is critical for tracking seizure patterns and guiding treatment.
The client diagnosed with ALS is prescribed an antiglutamate, riluzole (Rilutek). Which instruction should the nurse discuss with the client?
- A. Take the medication with food.
- B. Do not eat green, leafy vegetables.
- C. Use SPF 30 when going out in the sun.
- D. Report any febrile illness.
Correct Answer: D
Rationale: Riluzole can cause liver toxicity, and febrile illness (D) may indicate infection or drug reaction, requiring prompt reporting. Taking with food (A) is not required, green vegetables (B) are unrelated, and sun protection (C) is not specific.
The spouse of a recently retired man tells the nurse, 'All my husband does is sit around and watch television all day long. He is so irritable and moody. I don't want to be around him.' Which action should the nurse implement?
- A. Encourage the wife to leave the client alone.
- B. Tell the wife that he is probably developing Alzheimer's disease.
- C. Recommend that the client see an HCP for an antidepressant medication.
- D. Instruct the wife to buy him some arts and crafts supplies.
Correct Answer: C
Rationale: Irritability and mood changes post-retirement may indicate depression. Recommending an HCP evaluation for antidepressants (C) is appropriate. Leaving alone (A) ignores the issue, Alzheimer’s (B) is premature, and crafts (D) may not address mood.
During the immediate postoperative assessment, the nurse notices the dressing is moist. Which action is most appropriate to take first?
- A. Change the dressing.
- B. Reinforce the dressing.
- C. Remove the dressing.
- D. Document the findings.
Correct Answer: B
Rationale: Reinforcing the dressing controls minor drainage and maintains sterility while further assessment is conducted.