Nokea
The nurse is talking with the parents of a 4-year-old client. The parents are concerned because the client was previously toilet trained but has started wetting the bed again while hospitalized. Which of the following responses would be most appropriate for the nurse to make?
- A. Reinforcing any forgotten toileting behaviors during the hospital stay is beneficial.
- B. Restricting your child's fluid intake at night will resolve this issue.
- C. Your child may be purposefully misbehaving to gain your attention during the hospital stay.
- D. Your child may be reverting to behaviors from an earlier stage of development to cope with stress.
Correct Answer: D
Rationale: Regression, such as bedwetting, is common in hospitalized children due to stress (D). Reinforcing toileting behaviors (A) may help but doesn't address the underlying cause. Fluid restriction (B) is not appropriate without medical indication. Assuming misbehavior (C) dismisses the emotional impact of hospitalization.
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An adult client was admitted for congestive heart failure today. An IV is running. The nurse enters the room and notes that the client is having increased difficulty breathing. Before calling the physician, what action should the nurse take?
- A. Increase the IV drip rate
- B. Place the client in a supine position
- C. Ask the client if this has happened before
- D. Raise the head of the bed
Correct Answer: D
Rationale: Raising the head of the bed improves breathing in congestive heart failure by reducing pulmonary congestion. Increasing IV rate, supine positioning, or questioning delays intervention.
An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
- A. Have you had a recent heart attack?
- B. Do you become short of breath during your normal daily activities?
- C. How many pillows do you use at night to sleep comfortably?
- D. Do you smoke?
Correct Answer: B
Rationale: Do you become short of breath during your normal daily activities? This assesses for activity intolerance, a symptom of right-sided heart failure causing edema.
While caring for the client during the first hour after delivery, the nurse determines that the uterus is boggy and there is vaginal bleeding. What should be the nurse's first action?
- A. Check vital signs
- B. Massage the fundus
- C. Offer a bedpan
- D. Check for perineal lacerations
Correct Answer: B
Rationale: Massage the fundus. The nurse's first action should be to massage the fundus until it is firm, as uterine atony is the primary cause of bleeding in the first hour after delivery.
The wife of a 65 -year-old man says to the clinic nurse, 'I think the doctor should check out my husband's hearing. Either he is totally ignoring me and everyone else or he has a hearing problem.' How is the man likely to respond when the nurse asks him if he has difficulty hearing?
- A. I can hear women better than men.
- B. There's nothing wrong with my hearing. People around me just mumble a lot.
- C. I really need to get my hearing checked.
- D. Why should an old man like me care if he hears or not?
Correct Answer: B
Rationale: People who are losing their hearing usually complain that the people around them mutter. Denial is a very common response to hearing loss. Most older people who are having difficulties with hearing wait years before they will admit to hearing loss and accept treatment. Most older people who are losing their hearing hear lower frequencies (men's voices) better than higher frequencies (women's voices). Answer 4 not only indicates denial, but it also suggests that the client is in despair as opposed to ego integrity.
The nurse is caring for a client with schizophrenia. The client appears anxious and states, 'The voices are bad today; they sound so angry with me.' Which of the following responses would be most appropriate for the nurse to make?
- A. You should not listen to the voices.
- B. Remember that the voices are not real. Tell the voices to go away.
- C. What are the voices saying to you?
- D. That sounds frightening. Would you like medication to help you feel less anxious?
Correct Answer: D
Rationale: Acknowledging the client's fear and offering medication (D) is therapeutic and addresses anxiety. Dismissing voices (A, B) or probing content (C) may increase distress or reinforce delusions.