Nokea
The nurse is participating in a community health fair. As part of the assessments, the nurse should conduct a mental status examination when
- A. An individual displays restlessness
- B. There are obvious signs of depression
- C. Conducting any health assessment
- D. The resident reports memory lapses
Correct Answer: C
Rationale: Conducting any health assessment. A mental status examination is a critical part of baseline health assessments.
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The nurse knows that which psychosocial stage should be a priority to consider while planning care for a 20-year-old client?
- A. Identity versus identity diffusion.
- B. Intimacy versus isolation.
- C. Integrity versus despair and disgust.
- D. Industry versus inferiority.
Correct Answer: B
Rationale: is the stage for 19- to 35-year-olds
The doctor writes an order for piperacillin (Pipracil) 3 g IV q6h for an adult client.
Before administering this drug, the nurse should
- A. check for known allergies to medications.
- B. ensure that the client's respiratory rate is over 12.
- C. administer dexamethasone sodium phosphate (Decadron) 2 mg IV stat.
- D. check the client's blood pressure both sitting and standing.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is this a situation that requires assessment? Yes. Is there an appropriate assessment? Yes. (1) correct-assessment, piperacillin (Pipracil) is a semisynthetic broad-spectrum penicillin, should not be administered to clients with known allergies (2) assessment, not relevant for administration of this medication (3) implementation, not relevant for administration of this medication (4) assessment, not relevant for administration of this medication
A woman is admitted to the labor and delivery unit in a sickle cell crisis.
- A. Which nursing action is the highest priority for a woman in labor with a sickle cell crisis?
- B. Administer oxygen.
- C. Turn her to the right side.
- D. Provide adequate hydration.
- E. Start antibiotics.
Correct Answer: C
Rationale: Adequate hydration is the highest priority in sickle cell crisis to prevent further sickling of red blood cells and improve blood flow, reducing the risk of complications. Oxygen, repositioning, and antibiotics may be supportive but are not the primary intervention.
The nurse is teaching a client with a new diagnosis of osteoporosis about alendronate (Fosamax). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication first thing in the morning.
- B. I should remain upright for 30 minutes after taking it.
- C. I should take it with a full glass of water.
- D. I should take it with my calcium supplement.
Correct Answer: D
Rationale: Taking alendronate with a calcium supplement is incorrect, as it reduces absorption; they should be taken at different times. Options A, B, and C are correct: morning dosing, remaining upright, and taking with water minimize esophageal irritation and maximize absorption.
The physician has ordered insertion of a nasogastric tube to provide supplemental feedings for a client recovering from a stroke. To facilitate insertion of the nasogastric tube, the nurse should:
- A. Offer the client ice chips to swallow as the tube is advanced.
- B. Tell the client to flex his neck on his chest.
- C. Tell the client to hyperextend his neck.
- D. Place the tube in warm water.
Correct Answer: B
Rationale: Flexing the neck aligns the esophagus, facilitating nasogastric tube insertion. Ice chips increase choking risk. Hyperextension misaligns the airway. Warm water is ineffective.