Nokea
The nurse is reflecting on the client-nurse relationship. Which statement is correct regarding the orientation (introductory) phase of the relationship?
- A. identifying the client's strengths and limitations
- B. promoting the client's insight and perception of reality
- C. continuously evaluating progress toward the client's goals
- D. exploring feelings about the termination phase of the relationship
Correct Answer: A
Rationale: The orientation phase focuses on establishing trust and identifying the client’s strengths and limitations to guide care.
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A client has been diagnosed with immune thrombocytic purpura (ITP). Which of the following signs and symptoms indicate increased thrombocytopenia? Select all that apply.
- A. Frequent nosebleeds
- B. Petechiae and increased bruising
- C. Temporary changes in vision
- D. Numbness and tingling in distal limbs
- E. Confusion
Correct Answer: A,B
Rationale: ITP causes low platelets, leading to nosebleeds (A) and petechiae/bruising (B). Vision changes (C), numbness (D), and confusion (E) are not typical.
The charge nurse is formulating a discharge teaching plan for a client with mild preeclampsia. The nurse should give priority to:
- A. Teaching the client to report a nosebleed
- B. Instructing the client to maintain strict bed rest
- C. Telling the client to notify the doctor of pedal edema
- D. Advising the client to avoid sodium sources in the diet
Correct Answer: A
Rationale: A nosebleed may indicate worsening hypertension in preeclampsia, a critical symptom requiring immediate reporting.
A client experienced a major burn over 55% of his body 36 hours ago. The client is restless and anxious, and states, 'I am in pain.' There is a physician prescription for intravenous morphine. The nurse's first action would be to:
- A. Administer the morphine
- B. Assess respirations
- C. Assess urine output
- D. Check serum potassium levels
Correct Answer: B
Rationale: Assessing respirations is critical before administering morphine, as opioids can cause respiratory depression, especially in a burn client with potential airway compromise.
A pediatric nurse would be concerned by which of the following sets of vital signs?
- A. newborn: BP 70/50, RR 47, HR 135
- B. 12-month-old: BP 65/55, RR 50, HR 130
- C. 10-year-old: BP 110/70, RR 16, HR 89
- D. 13-year-old: BP 120/82, RR 15, HR 80
Correct Answer: B
Rationale: 12-month-old vitals (BP 65/55, RR 50, HR 130) show low BP (normal ~90/50) and high RR (normal 20-30), suggesting distress. Other options are age-appropriate.
The physician orders an MRI of the spine with infusion for an adult female. Which of the following findings in the client's history should the nurse report to the physician?
- A. allergy to shellfish
- B. congestive heart failure (CHF)
- C. chronic cystitis
- D. metformin administered daily
Correct Answer: A
Rationale: Shellfish allergy may indicate iodine sensitivity, a concern for MRI contrast, requiring physician evaluation to prevent allergic reactions.