Nokea
The nurse is teaching a client with a new diagnosis of depression about citalopram (Celexa). Which of the following statements by the client indicates a need for further teaching?
- A. I should report suicidal thoughts to my doctor.
- B. I should take this medication in the morning.
- C. I should avoid drinking alcohol.
- D. I should stop this medication if I feel better.
Correct Answer: D
Rationale: Stopping citalopram when feeling better is incorrect, as depression requires prolonged treatment to prevent relapse. Options A, B, and C are correct: suicidal thoughts require immediate reporting, morning dosing minimizes insomnia, and alcohol increases sedation.
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At approximately 6 PM, the nurse begins to open the nurses' notes for the evening shift. The last entry is noted for 1 PM, and there is no signature. The MOST appropriate nursing response is to
- A. leave approximately three or four lines for the day nurse to enter the day information and sign the chart.
- B. review with the client the activities after 1 PM, and enter what are determined to be the activities after 1 PM.
- C. begin charting on the next line below the last entry, and make a note for the day nurse to make a late entry to complete the chart.
- D. do not enter anything until the day nurse has been notified of the problem and returns to the unit to complete charting.
Correct Answer: C
Rationale: day nurse can make a 'late entry' to add any additional information
The nurse is caring for a postoperative patient. Four hours after surgery, the patient voids 200 cc of urine with a specific gravity of 1.019. The nurse should
- A. palpate the patient's lower abdomen for distention.
- B. encourage an increased intake of oral fluids.
- C. record the time and the amount of urine.
- D. encourage the patient to void again in two hours.
Correct Answer: C
Rationale: amount and specific gravity normal (1.010-1.030)
Which of the following activities documented by the recreational therapist following a community reorientation outing for a paraplegic client would indicate to the nurse a readiness for discharge?
- A. The client states that he/she enjoyed being outside the hospital environment.
- B. The client was able to participate in a structured team sport by keeping score.
- C. The client was independently able to order his meal and feed himself.
- D. The client was independent in transfers and wheelchair mobility.
Correct Answer: D
Rationale: correct, physical, these skills are requisite for discharge
The nurse is assessing a pregnant client with problems of mitral stenosis and congestive heart failure (CHF). Which of the following in the client's history would have a direct correlation with her current problem?
- A. History of rheumatic fever four years ago.
- B. Presence of ventricular septal defect as an infant.
- C. Heart disease in both the maternal and the paternal families.
- D. Persistent ear infections and mastoiditis as a child.
Correct Answer: A
Rationale: most common cause of mitral valve problems is a history of rheumatic fever with a subsequent complication of carditis, which affects the valve
A young client with a postoperative abdominal abscess had a drain inserted. Which of the following assessments by the nurse is BEST?
- A. Amount of the drainage.
- B. Character of the drainage.
- C. Consistency of the drainage.
- D. Amount of suction on the drainage system.
Correct Answer: B
Rationale: with this complication, the character of the drainage, purulent or otherwise, is a major priority to note and report