Nokea
The nurse is talking with the parent of a pediatric client who had a cast applied to the right arm 30 minutes ago. Which of the following statements by the parent would require follow-up?
- A. I understand that my child may feel tingling or burning underneath the cast for the first few days.
- B. I can use a hair dryer to blow cool air underneath the cast if my child experiences itching.
- C. I will call the clinic if my child experiences pain that is not relieved with medication.
- D. I should keep my child's arm elevated while resting for the first few days.
Correct Answer: A
Rationale: Tingling or burning may indicate neurovascular compromise or pressure on nerves, requiring immediate evaluation, not dismissal as normal.
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A client hospitalized with mania is racing wildly about the unit trying to organize the other clients into a game of Ping-Pong. The nurse should:
- A. Send the client to the recreation room for art therapy.
- B. Take the client outside for a walk.
- C. Allow the client to continue because his activities are goal directed.
- D. Suggest that the client do exercises to a video instead.
Correct Answer: B
Rationale: Taking the client for a walk redirects energy safely and reduces stimulation. Art therapy may not engage, continuing the activity risks escalation, and video exercises lack supervision.
The nurse is reviewing teaching about newly prescribed clonazepam with a client who is receiving palliative care for cancer. Which client statement shows a correct understanding of the nurse's teaching?
- A. I am glad that I can continue to take my kava supplement each morning.
- B. If I can't sleep, I will take some melatonin with my evening dose of clonazepam.
- C. If I feel restless, I can put some drops of lavender essential oil in a diffuser to calm myself.
- D. When my anxiety is getting really intense, I will drink some valerian tea to help me relax.
Correct Answer: C
Rationale: Lavender essential oil in a diffuser is a safe, non-pharmacological method to reduce restlessness, compatible with clonazepam without risk of interaction.
The nurse in the outpatient clinic is talking with the spouse of a client with borderline personality disorder. The client's spouse states, 'My spouse self-inflicts lacerations on the arms to stop me from traveling for business. My spouse's actions are not a serious attempt at self-harm.' Which of the following responses would be appropriate for the nurse to make?
- A. You should cancel your upcoming business trip.
- B. Your spouse should come to the clinic today to be assessed.
- C. It sounds like you are having a difficult time coping with your spouse's behavior.
- D. It is best to ignore your spouse's behavior because your spouse is doing this to gain attention.
Correct Answer: B
Rationale: Self-inflicted lacerations, even if not suicidal, indicate significant distress in borderline personality disorder and require professional assessment to ensure safety and address underlying issues.
The client has been vomiting for several days. Which blood gas values is he likely to have?
- A. pH=7.32; CO2=60; HCO3=30
- B. pH=7.32; CO2=33; HCO3=18
- C. pH=7.54; CO2=28; HCO3=22
- D. pH=7.54; CO2=32; HCO3=34
Correct Answer: C
Rationale: Prolonged vomiting causes metabolic alkalosis (high pH, low CO2) due to loss of stomach acid, matching pH=7.54, CO2=28, HCO3=22.
A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention?
- A. UAP has attached a bed alarm to the client's gown and bed
- B. UAP has been making hourly rounds on the client
- C. UAP has lowered the bed and raised all 4 side rails
- D. UAP has placed a fall risk ID bracelet on the client's wrist
Correct Answer: C
Rationale: Raising all four side rails is a restraint and can increase fall risk if the client attempts to climb over them. It also violates standards of care unless specifically prescribed.