Nokea
The nurse is teaching a client with a new diagnosis of hyperthyroidism about propylthiouracil (PTU). Which of the following statements by the client indicates a need for further teaching?
- A. I should report a fever to my doctor.
- B. I should take this medication with food.
- C. I should avoid eating shellfish.
- D. I should stop this medication if my thyroid levels are normal.
Correct Answer: D
Rationale: Stopping propylthiouracil when thyroid levels are normal is incorrect, as hyperthyroidism requires prolonged treatment to maintain euthyroid status. Options A, B, and C are correct: fever may indicate agranulocytosis, food reduces GI upset, and shellfish (iodine-rich) should be avoided.
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The nurse is preparing a client for a kidney-ureter-bladder x-ray (KUB). What is included in the preparation?
- A. Keeping the client NPO
- B. Explaining the procedure
- C. Catheterizing the client
- D. Administering an enema
Correct Answer: B
Rationale: Explaining the procedure reduces anxiety and ensures cooperation, a key preparation for a non-invasive KUB x-ray.
When the nurse walks into a client's room, the client states, 'I just love hot-blooded redheads.' The client pats his bed and says, 'Why don't you sit down here and get off your feet for a while.'
Which of the following responses by the nurse is BEST?
- A. I feel very uncomfortable when you make those suggestive remarks. It makes it difficult for me to do my job.'
- B. I don't think my husband or your wife would like me doing that.'
- C. You must be very lonesome. I'll come back later and spend some time with you.'
- D. I bet you flirt with all the nurses like that.'
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-nurse should confront client about inappropriate sexual behavior (2) should confront the client (3) reinforces inappropriate behavior (4) confront the client about inappropriate and unwanted behavior
An 18-month-old is brought by her father to the well-baby clinic for a routine immunization. Just before the nurse gives the child the injection, the toddler begins to cry.
Which of the following comments by the nurse is the MOST appropriate?
- A. Don't cry. It will be better if you try to behave.'
- B. I know you are frightened. It will be over with soon.'
- C. A big girl like you shouldn't cry. It's only going to hurt a little.'
- D. Please stop crying. There is nothing to be afraid of.'
Correct Answer: B
Rationale: Strategy: Remember therapeutic communication (1) nontherapeutic, doesn't respond to feeling tone and tells child what to do (2) correct-doesn't minimize child's reaction, responds to feeling tone (3) nontherapeutic, minimizes child's reaction (4) nontherapeutic, minimizes child's reaction, should indicate it is OK to feel afraid
The nurse is working with parents to plan home care for a 2 year-old with a heart problem. A priority nursing intervention would be to
- A. Encourage the parents to enroll in cardiopulmonary resuscitation (CPR) class
- B. Assist the parents to plan quiet play activities at home
- C. Stress to the parents the need to avoid overexertion
- D. Instruct the parents to avoid contact with persons with infection
Correct Answer: A
Rationale: Encourage the parents to enroll in cardiopulmonary resuscitation (CPR) class. While all suggestions are appropriate, the education of the parents/caregivers should include techniques of cardiopulmonary resuscitation in order to provide for emergency care of their child.
The nurse is caring for a client who is postoperative day 1 after a gastrectomy. Which of the following findings should the nurse report immediately?
- A. Pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Nasogastric tube output of 100 mL.
- D. Urine output of 40 mL/hour.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-gastrectomy complication. Options A, C, and D are normal.