Nokea
The nurse is talking with the parent of a 5-year-old client who is receiving morphine for pain. Which of the following statements by the parent would be a priority to follow up?
- A. My child may act aggressively when experiencing pain.
- B. I am concerned that my child thinks the pain is punishment.
- C. The FACES pain scale can be used to monitor my child's pain level.
- D. My child is playing and therefore does not need any pain medication now.
Correct Answer: D
Rationale: Assuming a playing child has no pain (D) is incorrect, as children may play despite pain. This requires follow-up to ensure adequate pain management. Aggression (A) and feeling punished (B) are valid concerns but less urgent. Using the FACES scale (C) is appropriate.
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A client who has been waiting for several hours in the clinic waiting room suddenly begins to shout, 'I need some attention and I need it now!' How should the nurse respond initially?
- A. Tell the client to be quiet and that she will be seen as soon as possible
- B. Immediately call security and the police
- C. Talk with the woman and determine her immediate needs
- D. Explain to the woman how busy the doctors are and that she will be seen soon
Correct Answer: C
Rationale: Engaging the client to assess her needs de-escalates agitation and addresses concerns. Silencing, calling security, or explaining delays may escalate tension.
The nurse has a client with knee surgery who is receiving patient-controlled analgesia (PCA) of meperidine (Demerol). Which assessment finding would be a priority due to the use of this device and medication?
- A. Pulse rate 108
- B. $100 \mathrm{cc}$ of green emesis
- C. Respiratory rate of 10
- D. Lack of pain relief
Correct Answer: C
Rationale: The patient is in danger of respiratory depression due to narcotic administration; therefore, this would be a priority assessment. Answer A does not relate to the PCA, so it is incorrect. Answer B is not a priority, making it wrong. Pain relief in answer D is important, but not as important as airway, so it is incorrect.
The intensive care nurse is caring for a client who has just been extubated. Which interventions are appropriate at this time?
- A. Administer prescribed oral narcotics for throat pain
- B. Administer warmed, humidified oxygen via facemask
- C. Give the client ice chips to moisten the mouth
- D. Provide mouth care with oral sponges
- E. Start the client on incentive spirometer
Correct Answer: B,C,D,E
Rationale: Post-extubation, warmed, humidified oxygen (B) prevents mucosal drying, ice chips (C) moisten the mouth, oral sponges (D) maintain hygiene, and incentive spirometry (E) promotes lung expansion. Oral narcotics (A) are risky due to potential airway compromise.
A 31-year-old client is admitted to the psychiatric unit after cutting both wrists with a kitchen knife. The client has a diagnosis of borderline personality disorder. The most therapeutic approach by the nurse is one that is:
- A. Warm and nurturing
- B. Open and flexible
- C. Firm and consistent
- D. Nonintrusive and passive
Correct Answer: C
Rationale: A firm and consistent approach provides structure and boundaries, which are therapeutic for clients with borderline personality disorder who often test limits.
The nurse caring for a terminally ill client asks if the client has an advance directive. The client states, 'I already have a power of attorney.' What is the best response by the nurse?
- A. A power of attorney (POA) is good to have in place. It sounds like you are on the right track.
- B. Great. Your POA can start to make decisions for you when you are no longer able to do so.
- C. Many people find a lawyer at this stage of life. A lawyer can help you get your affairs in order.
- D. There are many types of POAs. Let's clarify if your POA can make health care decisions for you.
Correct Answer: D
Rationale: Clarifying if the POA includes healthcare decisions (D) ensures proper advance directive planning. Vague affirmations (A, B) or suggesting a lawyer (C) do not address the need for a healthcare-specific POA.