Nokea
The nurse sees a substance abusing client occasionally in the outpatient clinic. In evaluating the client's progress, the nurse recognizes that the most revealing resistant behavior is
- A. Recurring crises
- B. Continuing drug use
- C. Rationalizing comments
- D. Missing appointments
Correct Answer: B
Rationale: Continuing drug use. Persistent substance use indicates lack of commitment to recovery and ongoing addiction.
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The nurse has administered sublingual nitroglycerin (Nitrostat) to a client complaining of chest pain.
Which of the following observations is MOST important for the nurse to report to the next shift?
- A. The client indicates the need to use the bathroom.
- B. Blood pressure has decreased from 140/80 to 90/60.
- C. Respiratory rate has increased from 16 to 24.
- D. The client indicates that the chest pain has subsided.
Correct Answer: B
Rationale: Strategy: The topic of the question is unstated. Read answer choices for clues. (1) not a side effect of this medication (2) correct-hypotension is significant side effect of nitroglycerin; although effect may be transient, BP should be closely observed to ensure that it does not continue to decrease (3) not a side effect of this medication (4) an expected outcome
Which of the following indicates that a client is beginning to develop a trusting relationship with the nurse?
- A. The client describes delusions to the nurse.
- B. The client can describe his/her feelings to the nurse.
- C. The nurse feels more comfortable with the client.
- D. The client reports feeling less anxious.
Correct Answer: B
Rationale: Sharing feelings indicates trust, a key to therapeutic relationships. Options A, C, and D are less direct indicators.
An adult client who had major abdominal surgery is returned to her room on the surgical nursing unit. The postanesthesia nurse reports that the client is awake and has stable vital signs. She has a nasogastric tube in place that is attached to intermittent suction. How should the nurse position the client?
- A. Supine
- B. Semi-sitting
- C. Dorsal recumbent
- D. Prone
Correct Answer: B
Rationale: Semi-sitting facilitates breathing, reduces aspiration risk with a nasogastric tube, and promotes comfort post-abdominal surgery. Supine or dorsal recumbent increases aspiration risk, and prone is contraindicated.
Immediately after surgery the client with an above-the-knee amputation of the right leg refuses to look at the operative site. The most immediate diagnosis that can be made is:
- A. Self-care deficit
- B. Potential for infection
- C. Disturbance in self-concept
- D. Cognitive deficit
Correct Answer: C
Rationale: Refusing to look at the operative site suggests a disturbance in self-concept, as the client may be struggling with acceptance of the altered body image post-amputation.
When a client is having a general tonic clonic seizure, the nurse should
- A. Hold the client's arms at their side
- B. Place the client on their side
- C. Insert a padded tongue blade in client's mouth
- D. Elevate the head of the bed
Correct Answer: B
Rationale: Place the client on their side. This position maintains a patent airway and prevents aspiration.