Nokea
The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks' gestation. An appropriate response by the nurse would be:
- A. It must be God's will and probably is for the best.'
- B. This must be a difficult time for you. Would you like to talk about it?'
- C. I'm sure your other children will be a comfort for you.'
- D. Don't worry, you're still young. If I were you I'd just try again.'
Correct Answer: B
Rationale: This response is nontherapeutic because it belittles the client's response and gives a meaningless rationalization. This response acknowledges the client's feelings and demonstrates the therapeutic offering of self by the nurse. This response is nontherapeutic because it does not focus on the client's feelings and offers false reassurance. This response is nontherapeutic because it belittles the client's feelings and offers her advice.
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The nurse would teach a male JOB client ways to minimize the risk of infection after eye surgery. Which of the following indicates the client needs further teaching?
- A. I will wash my hands before instilling eye medications.'
- B. I will wear sunglasses when going outside.'
- C. I will wear an eye patch for the first 3 postoperative days.'
- D. I will maintain the sterility of the eye medications.'
Correct Answer: C
Rationale: Eye patches are typically worn during sleep or naps, not constantly for 3 days, indicating a need for further teaching. The other options are correct preventive measures.
The nurse is caring for a client with a history of a fractured humerus who is in a sling. The nurse should:
- A. Apply ice to the fracture site
- B. Encourage active range of motion
- C. Keep the arm in a dependent position
- D. Massage the arm daily
Correct Answer: A
Rationale: Ice reduces swelling and pain at the fracture site. Active motion is limited, dependent positioning increases swelling, and massage is not recommended.
A newborn weighed seven pounds at birth. At six months of age, the infant could be expected to weigh:
- A. 14 pounds
- B. 18 pounds
- C. 25 pounds
- D. 30 pounds
Correct Answer: A
Rationale: Infants typically double their birth weight by 6 months. A 7-pound newborn would weigh approximately 14 pounds at 6 months. The other weights are excessive or unrealistic.
The client with chronic renal failure is prescribed aluminum hydroxide (Amphojel). The purpose of this medication is to:
- A. Reduce serum phosphate levels
- B. Increase urine output
- C. Prevent gastric ulcers
- D. Promote bowel elimination
Correct Answer: A
Rationale: Aluminum hydroxide binds dietary phosphate in the gut, reducing serum phosphate levels in chronic renal failure, where kidneys cannot excrete phosphate. It does not affect urine output, ulcers, or bowel elimination directly.
Diabetes during pregnancy requires tight metabolic control of glucose levels to prevent perinatal mortality. When evaluating the pregnant client, the nurse knows the recommended serum glucose range during pregnancy is:
- A. 70 mg/dL and 120 mg/dL
- B. 100 mg/dL and 200 mg/dL
- C. 40 mg/dL and 130 mg/dL
- D. 90 mg/dL and 200 mg/dL
Correct Answer: A
Rationale: The recommended range is 70-120 mg/dL to reduce the risk of perinatal mortality. (B, C, D) These levels are not recommended. The higher the blood glucose, the worse the prognosis for the fetus. Hypoglycemia can also have detrimental effects on the fetus.