Nokea
The nurse is talking with a client whose spouse recently attempted suicide. The client states, 'If I had not intervened, my spouse would have died. I cannot believe this is happening.' Which of the following responses would be most appropriate for the nurse to make?
- A. Do not focus on the negative. You should try to focus on helping your spouse get better.
- B. I imagine that this is overwhelming. Tell me more about how you are feeling right now.
- C. Do you have any relatives or close friends who can help support you through this?
- D. Has your spouse been experiencing worsening depression recently?
Correct Answer: B
Rationale: Acknowledging the client's feelings and encouraging expression provides emotional support.
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The nurse is caring for several clients. When thinking about long-term goals, the nurse knows that which of these clients has the best prognosis?
- A. A young adult who has stage I Hodgkin's lymphoma
- B. A young adult who has leukemia
- C. A young adult who has osteosarcoma
- D. A 50-year-old who has multiple myeloma
Correct Answer: A
Rationale: Stage I Hodgkin's lymphoma has a high cure rate (over 90%) with treatment, offering the best prognosis compared to leukemia, osteosarcoma, or multiple myeloma.
Which tasks are appropriate for the nurse in a long-term care unit to delegate to unlicensed assistive personnel? Select all that apply.
- A. Assign lunch times to other unlicensed assistive personnel on the unit
- B. Assist a client with bathing and changing an ostomy appliance
- C. Collect vital signs on a client newly arrived on the unit
- D. Pick up a prescribed oral antibiotic from the pharmacy
- E. Record intake and output for a client with chronic neurogenic bladder
Correct Answer: C,E
Rationale: Collecting vital signs and recording intake/output are within the scope of unlicensed assistive personnel. Other tasks require nursing judgment or are outside their scope.
The nurse is offering safety instructions to a parent with a four month-old infant and a four year-old child. Which statement by the parent indicates understanding of appropriate precautions to take with the children?
- A. I strap the infant car seat on the front seat to face backwards.'
- B. I place my infant in the middle of the living room floor on a blanket to play with my four year-old while I make supper in the kitchen.'
- C. My sleeping baby lies so cute in the crib with the little buttocks stuck up in the air while the four year-old naps on the sofa.'
- D. I have the four year-old hold and help feed the four month-old a bottle in the kitchen while I make supper.'
Correct Answer: D
Rationale: The infant seat is to be placed on the rear seat. Small children and infants are not to be left unsupervised. Option D indicates supervision and age-appropriate responsibility.
The nurse is reviewing recommended dietary modifications with a client with celiac disease. Which of the following menu selections by the client would indicate a correct understanding of the teaching? Select all that apply.
- A. Beef barley soup with mixed vegetables and French bread
- B. Corn tortilla tacos with ground beef and cheese
- C. Grilled chicken, baked potato, and strawberry yogurt
- D. Peanut butter and jelly on whole wheat bread and an apple
- E. Rice noodles with chicken and broccoli
Correct Answer: B,C,E
Rationale: Corn tortillas, grilled chicken with potato/yogurt, and rice noodles are gluten-free, suitable for celiac disease. Barley and wheat contain gluten.
The nurse is caring for a 67-year-old client with postherpetic neuralgia who has a new prescription for amitriptyline. Which of the following actions would be a priority for the nurse to take?
- A. Schedule frequent rest periods for the client.
- B. Encourage the client to increase the intake of fluids.
- C. Instruct the client to stand up slowly from a sitting position.
- D. Remind the client to wear sunglasses when spending time outdoors.
Correct Answer: C
Rationale: Amitriptyline can cause orthostatic hypotension, making slow position changes a priority to prevent falls.