Nokea
The nurse is talking with the parents of an adolescent client who was brought to the emergency department after making superficial cuts on the arms with a razor blade. There are several cuts in various stages of healing on the client’s forearms. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
- A. This must be difficult for you
- B. Everything is going to be alright
- C. We have cleaned and bandaged the cuts
- D. Why did you wait until now to bring your child here?
- E. Tell me about when you started noticing this behavior
Correct Answer: A,C,E
Rationale: Acknowledging difficulty, confirming care, and exploring behavior onset are supportive and therapeutic. Assuring everything will be alright is dismissive, and questioning delay is judgmental.
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Home Medications
Vital signs
Temperature 98.5 F (36.9 C)
Blood pressure 110/74 mm Hg
Heart rate 68/min
Respirations 16/min
SpO2 97% on room air
Medication Prescription
Medication prescription
Clopidogrel: 75 mg PO, daily
Metoprolol XL: 50 mg PO, daily
Furosemide: 40 mg PO, twice daily
Fish oil: 4 g PO, daily
Intake and Output Record
Intake and output record
Time Oral Intake Output
0700 200 mL
0800 125 mL
1000 100 mL 250 mL
1200 200 mL 250 mL
1500 150 mL 375 mL
The nurse is caring for a client with coronary artery disease and heart failure. Which of the following findings would require immediate follow-up?
- A. bruises easily on the arms
- B. reports chronic fatigue
- C. muscle cramps in the legs
- D. reports feeling depressed
Correct Answer: C
Rationale: Hypokalemia (serum potassium <3.5 mEq/L [<3.5 mmol/L]) is a common adverse effect of potassium-wasting diuretics (eg,furosemide) that may cause leg cramps, muscle weakness, or ECG changes. Unmanaged hypokalemia can lead to lethal cardiac dyshythmias (eg, ventricular fibrillation, torsades de pointes) and paralysis. Therefore, the nurse should immediately notify the health care provider of symptoms of hypokalemia
A client diagnosed with stable angina is being discharged home on the cholesterol-lowering drug rosuvastatin. The nurse should reinforce the need to report which symptom?
- A. Abdominal discomfort
- B. Insomnia
- C. Morning headache
- D. Muscle aches or weakness
Correct Answer: D
Rationale: Muscle aches or weakness may indicate myopathy or rhabdomyolysis, serious rosuvastatin side effects. Abdominal discomfort, insomnia, and headaches are less specific.
The nurse in the outpatient care facility is caring for a client with metastatic lung cancer who received chemotherapy 3 days ago. The client states, 'I have decided that I do not want to continue treatment.' Which of the following responses would be appropriate for the nurse to make?
- A. That is not an easy choice to make. I will notify your health care provider of your decision
- B. Have you considered how this decision might affect your spouse and children?
- C. I do not think it is wise to stop chemotherapy. You will become too sick to enjoy your life
- D. Have you discussed this decision with someone else that you trust?
Correct Answer: A
Rationale: Acknowledging the decision’s difficulty and notifying the provider respects autonomy and ensures follow-up. Other responses judge, guilt, or deflect the client’s choice.
The father of an 8 month-old infant asks the nurse if his child's vocalizations are normal for his age. Which of the following would the nurse expect at this age?
- A. Cooing
- B. Imitation of sounds
- C. Throaty sounds
- D. Laughter
Correct Answer: B
Rationale: Imitation of sounds. Eight-month-olds typically imitate sounds like 'da-da' as part of language development.
The nurse is giving home care to an elderly client with angina pectoris and Type 2 diabetes mellitus. Which observation is of most concern and should be reported immediately?
- A. The client reports chest discomfort yesterday while taking a walk.
- B. The nurse observes several brown spots on the client's arms and legs.
- C. The client reports an ingrown toenail that is getting more painful.
- D. The client reports shortness of breath when climbing stairs.
Correct Answer: A
Rationale: Chest discomfort in a client with angina suggests possible cardiac ischemia, requiring immediate reporting to prevent myocardial infarction. Brown spots, toenail pain, or exertional dyspnea are less urgent.