Nokea
The nurse is providing care to a client with posttraumatic stress disorder following a terrorist attack at the client's place of worship. The client says, 'I'm just so worried all the time. I will never be safe again!' What is the priority nursing action?
- A. Acknowledge the client's feelings
- B. Assess the client's support system
- C. Encourage the client to talk about the trauma
- D. Offer the client a PRN sleep medication
Correct Answer: A
Rationale: Acknowledging feelings (A) builds trust and validates the client's experience, making it the priority. Assessing support (B), discussing trauma (C), or offering medication (D) are secondary.
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The nurse caring for a 2-year-old client should expect the child to be able to perform which of the following actions? Select all that apply.
- A. Draw a square
- B. Hop on one foot
- C. Kick a large ball
- D. Use 2-word phrases
- E. Walk without help
Correct Answer: C, D, E
Rationale: A 2-year-old can kick a ball (C), use 2-word phrases (D), and walk without help (E). Drawing a square (A) and hopping on one foot (B) are skills typically developed later.
Laboratory reference ranges
INR (Therapeutic – atrial fibrillation)
2.0-3.0
The nurse has reinforced teaching for a client with atrial fibrillation who is receiving warfarin. Which of the following statements by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. Antibiotics can affect my INR value.'
- B. I am going to eat more leafy green vegetables.'
- C. I will take the medication at the same time every day.'
- D. I understand that my INR value should be between 4 and 5.'
- E. If I miss a dose of medication, I'll double my dose the next day.'
Correct Answer: A, C
Rationale: Antibiotics affecting INR (A) and consistent timing (C) are correct. More leafy greens (B) can lower INR, INR of 4-5 (D) is too high, and doubling doses (E) is dangerous.
The nurse is caring for an assigned team of clients. Which client is the priority for the nurse at this time?
- A. Client admitted with Guillain-Barré syndrome yesterday is paralyzed to the knees
- B. Client admitted with multiple sclerosis exacerbation has scanning speech
- C. Client with epilepsy puts on call light and reports having an aura
- D. Client with fibromyalgia reports pain in the neck and shoulders
Correct Answer: C
Rationale: An aura (C) indicates an impending seizure, requiring immediate intervention to ensure safety. Guillain-Barré (A), multiple sclerosis (B), and fibromyalgia (D) are less acute at this moment.
In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?
- A. White patches
- B. Green drainage
- C. Reddened tissue
- D. Eschar development
Correct Answer: C
Rationale: Reddened tissue. Redness indicates granulation tissue formation, a sign of healing.
Which of the following toys is the most appropriate for a 2-year old with Tetralogy of Fallot?
- A. A toy horn
- B. A stethoscope
- C. A push-pull toy
- D. A shape sorter
Correct Answer: C
Rationale: A push-pull toy encourages gentle physical activity suitable for a 2-year-old with Tetralogy of Fallot, who may tire easily. A toy horn requires exertion, a stethoscope is not age-appropriate, and a shape sorter is sedentary.