Nokea
The nurse is observing a staff member talking with the parent of a pediatric client. The parent is crying and states, 'I do not know what to do about this situation with my child.' The staff member responds, 'I am sure you will do the right thing.' The nurse should recognize that the staff member's response
- A. expresses interest in the parent's concern
- B. demonstrates respect for the parent's privacy
- C. devalues the parent's feelings and gives false reassurance
- D. conveys empathy toward the parent and promotes self-confidence
Correct Answer: C
Rationale: The response (C) dismisses the parent's distress and provides false reassurance, lacking empathy. It does not express interest (A), respect privacy (B), or convey empathy (D).
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An adult has been taking captopril (Capoten) for hypertension. The client tells the nurse that he has a dry cough and sometimes gets dizzy when he stands up. What conclusions should the nurse make regarding this client?
- A. The client is having severe side effects and should discontinue the drug until after he sees his physician.
- B. Dizziness is a common side effect of antihypertensives. The cough is probably unrelated to the medication.
- C. A dry cough is a common side effect of angiotensin-converting enzyme (ACE) inhibitors. The client should stand up slowly to avoid orthostatic hypotension, a common side effect of antihypertensives.
- D. Cough is a serious side effect and usually results in discontinuing the medication. The dizziness will get better with time.
Correct Answer: C
Rationale: Dry cough and orthostatic hypotension are common ACE inhibitor side effects; slow position changes mitigate dizziness, and cough may require evaluation.
The nurse preparing an educational seminar on sexually transmitted infections for female college students should advise that which 2 infections are leading causes of pelvic inflammatory disease and infertility?
- A. Genital herpes and HIV
- B. Gonorrhea and chlamydia
- C. Human papillomavirus and syphilis
- D. Yeast and trichomoniasis
Correct Answer: B
Rationale: Gonorrhea and chlamydia (B) are bacterial infections that commonly cause pelvic inflammatory disease and infertility if untreated. Other options are less associated with these outcomes.
The nurse is reinforcing teaching for a client with suspected Cushing syndrome who has a 24-hour urine specimen. Which of the following information should the nurse reinforce? Select all that apply.
- A. An indwelling urinary catheter will be inserted for this test and your urine will be collected in an attached drainage bag.
- B. Discard your first void in the toilet and then record the start time of the urine collection so that the start time coincides with an empty bladder.
- C. Keep the collection container in the refrigerator or a cooled ice chest when it is not in use.
- D. Only daytime urine should be collected in the container because cortisol levels are higher in the morning.
- E. You will be given an opaque plastic container to collect your urine to protect it from light.
Correct Answer: B,C
Rationale: Discarding the first void and recording the start time (B) ensures accurate collection, and refrigerating the container (C) preserves the sample. Catheters (A) are not needed, all urine is collected (D is incorrect), and light protection (E) is unnecessary.
A client with chronic heart failure is being discharged home on furosemide and supplementary potassium chloride tablets. Which instructions related to the potassium supplement should the nurse reinforce to the client?
- A. A diet rich in protein and vitamin D will help with absorption.
- B. If the tablet is too large to swallow, crush and take it in applesauce or pudding.
- C. Potassium tablets should be taken on an empty stomach.
- D. Take it with plenty of water and sit upright for a period of time afterward.
Correct Answer: D
Rationale: Potassium chloride tablets should be taken with water and the client should remain upright to prevent esophageal irritation or ulceration (D). Protein and vitamin D (A) do not enhance absorption, crushing tablets (B) can cause irritation, and taking on an empty stomach (C) is unnecessary.
The health care provider (HCP) explains the risks and benefits of a procedure to the client through an interpreter. The HCP leaves after asking the nurse to witness the client's signature on the consent. The interpreter and client now have a lengthy discussion in the foreign language. The nurse should take which action at this time?
- A. Ask the interpreter to explain the discussion
- B. Confirm the client's consent with the interpreter, using gestures
- C. Have the interpreter witness the signature
- D. Indicate that the interpreter was used when witnessing the client's signature
Correct Answer: A
Rationale: Asking the interpreter to explain the discussion (A) ensures the nurse understands any concerns or clarifications, verifying informed consent. Gestures (B) are unreliable, the interpreter witnessing (C) is inappropriate, and noting interpreter use (D) is insufficient without understanding the discussion.