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The physician has ordered insertion of a nasogastric tube to provide supplemental feedings for a client recovering from a stroke. To facilitate insertion of the nasogastric tube, the nurse should:
- A. Offer the client ice chips to swallow as the tube is advanced.
- B. Tell the client to flex his neck on his chest.
- C. Tell the client to hyperextend his neck.
- D. Place the tube in warm water.
Correct Answer: B
Rationale: Flexing the neck aligns the esophagus, facilitating nasogastric tube insertion. Ice chips increase choking risk. Hyperextension misaligns the airway. Warm water is ineffective.
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The physician diagnoses Graves' disease for a 28-year-old woman seen in the clinic. The nurse would expect the client to exhibit which of the following symptoms?
- A. Lethargy in the early morning.
- B. Sensitivity to cold.
- C. Weight loss of 10 lb in 3 weeks.
- D. Reduced deep tendon reflexes.
Correct Answer: C
Rationale: increased metabolic rate causes weight loss even with increased appetite
The nurse is teaching a community group about healthy lifestyles to prevent cancer and heart disease. Which comment by a member of the group indicates a need for more teaching?
- A. Smoking is not good for you.'
- B. Reducing fat intake helps reduce the risk of heart disease.'
- C. Walking every day puts a strain on your heart.'
- D. Eating lots of fruits and vegetables helps keep me healthy.'
Correct Answer: C
Rationale: Daily walking strengthens the heart, reducing cardiovascular risk, not straining it. The other statements align with healthy lifestyle practices.
Delirium tremens could best be described as
- A. Disorganized thinking, feelings of terror and non-purposeful behavior
- B. A generalized shaking of the body accompanied by repetitive thoughts
- C. An excited state accompanied by disorientation, hallucination and tachycardia
- D. Single or multiple jerks caused by rapid contracting muscles
Correct Answer: C
Rationale: An excited state accompanied by disorientation, hallucination and tachycardia. Delirium tremens involves severe withdrawal symptoms, including confusion, hallucinations, and autonomic hyperactivity.
After admission for elective surgery, an adult says to the nurse, 'They asked me if I had advance directives. I don't even know what that is.' What is the best response by the nurse?
- A. Advance directives are usually written by persons who have a terminal illness. They are not indicated for elective surgery.
- B. An advance directive is a document that tells the medical and nursing staff what your wishes are regarding certain health care items should you not be able to make decisions for yourself.
- C. An advance directive includes information about you and your specific medical history that could be important to care givers if you are not alert.
- D. Advance directives direct your family about your plans for distributing your belongings when you are no longer here.
Correct Answer: B
Rationale: Advance directives specify healthcare preferences for incapacitation, relevant for any adult, clearly explaining their purpose.
The nurse is caring for a client with a history of asthma who is receiving montelukast (Singulair) 10 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I take my medication at night.
- B. I have a headache sometimes.
- C. I feel sad and hopeless.
- D. I use my albuterol inhaler when I wheeze.
Correct Answer: C
Rationale: Feeling sad and hopeless suggests depression, a rare but serious side effect of montelukast, requiring immediate evaluation. Options A, B, and D are less concerning: nighttime dosing is standard, headaches are nonspecific, and albuterol use is appropriate.