Nokea
The nurse is teaching a client with gastroesophageal reflux disease (GERD) about lifestyle modifications. Which of the following statements by the client indicates a need for further teaching?
- A. I should avoid lying down for 2 hours after eating.
- B. I should eat smaller, more frequent meals.
- C. I should avoid drinking coffee in the evening.
- D. I should sleep on my right side to reduce reflux.
Correct Answer: D
Rationale: Sleeping on the right side can worsen GERD by allowing acid to reflux into the esophagus; the left side or head elevation is preferred. Options A, B, and C are correct: avoiding lying down post-meal, eating smaller meals, and avoiding coffee reduce reflux.
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A laboring woman says to the LPN/LVN, 'My baby is coming! My baby is coming!' She was last checked 15 minutes ago and was 5 cm dilated. What should the LPN/LVN do initially?
- A. Have her checked to see if she has progressed
- B. Reassure her that she cannot be that far along
- C. Reposition her to begin pushing
- D. Request medication to help her relax
Correct Answer: A
Rationale: Urgent reports of delivery sensation require immediate cervical check to confirm progression, as rapid labor can occur, ensuring timely intervention.
A young female teenager describes a brutal assault and rape to the nurse on duty. Which of the following actions should the nurse take first?
- A. Check with case manager on duty about possible police intervention.
- B. Provide an environment of concern and emotional stabilization.
- C. Clean the patient's wounds with normal saline and gauze.
- D. Recommend a good attorney to the patient.
Correct Answer: B
Rationale: Emotional support is what that patient needs most at this point in time.
The nurse is caring for a client with a history of schizophrenia who is receiving haloperidol (Haldol) 5 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel stiff when I walk.
- B. I have a dry mouth.
- C. I feel sleepy in the afternoon.
- D. I have a headache sometimes.
Correct Answer: A
Rationale: Stiffness when walking suggests extrapyramidal symptoms (EPS), a serious side effect of haloperidol, requiring evaluation for possible dose adjustment or antiparkinsonian medication. Options B, C, and D are common, less urgent side effects: dry mouth, sedation, and headaches.
The home nurse who is caring for an older person who has chronic obstructive pulmonary disease (COPD) with continuous nasal oxygen is helping the family set up a humidifier in the room. The humidifier cord is not long enough to reach the outlet in the room and must be plugged into an extension cord. The extension cord is wrapped with black tape. When the nurse asks the family members about the tape, they reply that the cord is an old cord, and the electrical tape covers up the frayed part and makes it safe. They say a contractor friend told them how to make it safe. How should the nurse respond?
- A. Refuse to set up the equipment until a new cord is available
- B. Carefully inspect the taped area and set up equipment if it appears intact
- C. Ask the family to let the nurse discuss the safety of the cord with the contractor friend
- D. Set up the equipment and suggest that the family get a new extension cord as soon as possible
Correct Answer: A
Rationale: A frayed cord poses a fire hazard, especially with oxygen use. Refusing to set up until a safe cord is available prioritizes safety.
The nurse is developing a comprehensive care plan for a young woman with an eating disorder. The nurse refers this client to assertiveness skills classes. The nurse knows that this is an appropriate intervention because this client may have problems with
- A. aggressive behaviors and angry feelings.
- B. self-identity and self-esteem.
- C. focusing on reality.
- D. family boundary intrusions.
Correct Answer: B
Rationale: clients with eating disorders experience difficulty with self-identity and self-esteem, which inhibits their abilities to act assertively; some assertiveness techniques that are taught include giving and receiving criticism, giving and accepting compliments, accepting apologies, being able to say no, and setting limits on what they can realistically do rather than just doing what others want them to do