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The nurse is providing diversional activities for a 4-year-old client who is on long-term, strict bed rest. Which of the following toys would be most appropriate to provide for the client?
- A. Card game
- B. Board game
- C. Soap bubbles
- D. Plastic medical kit
Correct Answer: C
Rationale: Soap bubbles are safe, engaging, and can be used while on strict bed rest, promoting activity without physical exertion. Card and board games may require setup or movement, and a medical kit may cause anxiety.
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A client is admitted with a possible gastric ulcer. Suddenly he calls to the nurse and says, 'It hurts so bad.' The client is pale and diaphoretic. What should the nurse do initially?
- A. Call the physician
- B. Touch the abdomen
- C. Obtain a stool for guaiac
- D. Place the client in a supine position
Correct Answer: A
Rationale: Sudden severe pain with pallor and diaphoresis suggests ulcer perforation, requiring immediate physician notification for urgent intervention.
A new nurse on the unit notes that the nurse manager seems to be highly respected by the nursing staff. The new nurse is surprised when one of the nurses states: 'The manager makes all decisions and rarely asks for our input.' The best description of the nurse manager's management style is
- A. Participative or democratic
- B. Ultraliberal or communicative
- C. Autocratic or authoritarian
- D. Laissez faire or permissive
Correct Answer: C
Rationale: Autocratic or authoritarian. The manager’s decision-making without staff input indicates an autocratic leadership style.
The nurse is contributing to the plan of care for a newly admitted client with schizophrenia who is experiencing persecutory delusions. Which of the following interventions should the nurse suggest including in the client's plan of care?
- A. Explore the meaning behind the client's delusions
- B. Focus on the client's feelings related to the delusions
- C. Gently attempt to convince the client that the delusions are false
- D. Present the client with logical arguments to discredit the delusions
Correct Answer: B
Rationale: Focusing on the client's feelings related to delusions helps build trust and validates their emotional experience without reinforcing the delusion. Exploring meanings or challenging delusions directly can escalate distress or resistance, as delusions are fixed beliefs in schizophrenia.
Central venous access devices (CVADs) are frequently utilized to administer chemotherapy. What is an advantage of using CVADs for chemotherapeutic agent administration?
- A. CVADs are less expensive than a peripheral IV.
- B. Weekly administration is possible.
- C. Chemotherapeutic agents can be caustic to smaller veins.
- D. The client or family can administer the drug at home.
Correct Answer: C
Rationale: Many chemotherapeutic agents are vesicants, damaging smaller peripheral veins. CVADs allow safe administration into larger veins. CVADs are more expensive, dosing varies, and home administration is rare. Pharmacological Therapies
Quality is defined as a combination of all of the following except:
- A. conforming to standards.
- B. performing at the minimally acceptable level.
- C. meeting or exceeding customer requirements.
- D. exceeding customer expectations.
Correct Answer: B
Rationale: Quality care involves meeting or exceeding standards and expectations, not merely performing at a minimal level, which is insufficient for quality. Coordinated Care