Nokea
The practical nurse (PN) is assisting with care for a 1-day-old client who is irritable, feeding poorly, and only sleeping for very short intervals. The newborn's mother has been taking hydrocodone on a regular basis for several years. When collaborating with the registered nurse to develop the plan of care, which intervention should the PN include?
- A. Avoid giving the newborn a pacifier
- B. Position the newborn supine after feeding
- C. Stimulate the newborn with light regularly
- D. Swaddle and gently rock the newborn
Correct Answer: D
Rationale: Swaddling and rocking (D) soothe a newborn with neonatal abstinence syndrome due to maternal hydrocodone use. Pacifiers (A) are helpful, supine positioning (B) is for safety but not soothing, and stimulation (C) may worsen irritability.
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The wife of a 65 -year-old man says to the clinic nurse, 'I think the doctor should check out my husband's hearing. Either he is totally ignoring me and everyone else or he has a hearing problem.' How is the man likely to respond when the nurse asks him if he has difficulty hearing?
- A. I can hear women better than men.
- B. There's nothing wrong with my hearing. People around me just mumble a lot.
- C. I really need to get my hearing checked.
- D. Why should an old man like me care if he hears or not?
Correct Answer: B
Rationale: People who are losing their hearing usually complain that the people around them mutter. Denial is a very common response to hearing loss. Most older people who are having difficulties with hearing wait years before they will admit to hearing loss and accept treatment. Most older people who are losing their hearing hear lower frequencies (men's voices) better than higher frequencies (women's voices). Answer 4 not only indicates denial, but it also suggests that the client is in despair as opposed to ego integrity.
A client admitted to the floor 3 days after a bowel resection suddenly develops chest pain and shortness of breath. Assessment of the client reveals rales, BP 160/40, and severe tachycardia. The nurse's first action should be to:
- A. Apply O2 at 2 L/minute via mask.
- B. Begin chest compressions.
- C. Place the client in high Fowler's position.
- D. Administer a prescribed sedative.
Correct Answer: C
Rationale: The symptoms suggest a pulmonary embolus, a medical emergency. Placing the client in high Fowler's position facilitates breathing. Oxygen is secondary, chest compressions are inappropriate without cardiac arrest, and sedatives could worsen respiratory distress.
The nurse is caring for a client with schizophrenia. The client appears anxious and states, 'The voices are bad today; they sound so angry with me.' Which of the following responses would be most appropriate for the nurse to make?
- A. You should not listen to the voices.
- B. Remember that the voices are not real. Tell the voices to go away.
- C. What are the voices saying to you?
- D. That sounds frightening. Would you like medication to help you feel less anxious?
Correct Answer: D
Rationale: Acknowledging the client's fear and offering medication (D) is therapeutic and addresses anxiety. Dismissing voices (A, B) or probing content (C) may increase distress or reinforce delusions.
A client with a diagnosis of HPV is at risk for which of the following?
- A. Hodgkin's lymphoma
- B. Cervical cancer
- C. Multiple myeloma
- D. Ovarian cancer
Correct Answer: B
Rationale: The client with HPV is at higher risk for cervical and vaginal cancer related to this STI. She is not at higher risk for the cancers mentioned in answers A, C, and D, so those are incorrect.
The practical nurse is assisting the registered nurse in assessing a child with attention-deficit hyperactivity disorder at the clinic for a well-child visit. The client has been taking methylphenidate for a year. What are the priority nursing assessments?
- A. Attention span and activity level
- B. Dental health and mouth dryness
- C. Height/weight and blood pressure
- D. Progress with schoolwork and in making friends
Correct Answer: C
Rationale: Methylphenidate can affect growth (height/weight) and increase blood pressure (C), making these priority assessments. Attention and activity (A) are relevant but secondary. Dental health (B) and social progress (D) are less critical for medication monitoring.