Nokea
The preoperative client is from a different country and tells the nurse that his family will be coming for a prayer service. Eighteen persons arrive and start chanting in the client's semiprivate room. What is the best response for the nurse?
- A. Explain that visitors are limited to two per client
- B. Ask the client's roommate if he/she objects to so many persons in the room
- C. Ignore the large number of people and the chanting
- D. Arrange for the group to go to the conference room or the chapel
Correct Answer: D
Rationale: Arranging for a private space respects cultural practices while minimizing disruption to the roommate, balancing sensitivity and practicality.
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The nurse is teaching a client with a new diagnosis of chronic obstructive pulmonary disease (COPD) about tiotropium (Spiriva). Which of the following statements by the client indicates a need for further teaching?
- A. I should rinse my mouth after using this inhaler.
- B. I should use this inhaler once a day.
- C. I should report eye pain to my doctor.
- D. I should use this inhaler when I have trouble breathing.
Correct Answer: D
Rationale: Using tiotropium as a rescue inhaler is incorrect, as it is a long-acting maintenance medication for COPD, not for acute symptoms. Options A, B, and C are correct: rinsing prevents oral thrush, daily use is standard, and eye pain may indicate glaucoma.
A 3 year-old child is brought to the clinic by his grandmother to be seen for 'scratching his bottom and wetting the bed at night.' Based on these complaints, the nurse would initially assess for which problem?
- A. allergies
- B. scabies
- C. regression
- D. pinworms
Correct Answer: D
Rationale: Pinworms are a common cause of anal itching and can contribute to bed-wetting in children due to discomfort. The nurse should assess for signs of pinworm infection, such as observing the anal area for worms or performing a tape test.
A client who has a strong family history of breast cancer tells the nurse that she is taking a drug to prevent breast cancer. The nurse expects the drug that she is receiving is:
- A. Tamoxifen (Nolvadex)
- B. Cyclophosphamide (Cytoxan)
- C. Estrogen (Premarin)
- D. Doxorubicin (Adriamycin)
Correct Answer: A
Rationale: Tamoxifen is used for breast cancer prevention in high-risk individuals due to its anti-estrogenic effects. Cyclophosphamide and Doxorubicin are chemotherapy drugs, not preventive, so B and D are incorrect. Estrogen can increase breast cancer risk, making C incorrect.
At 10:00 A.M., the nurse discovers a 75-year-old woman who is hospitalized with congestive heart failure on the floor beside the bed. She has a bruise on her leg, but x-rays reveal no fractures. How should the nurse record the incident in the client's chart?
- A. Client fell out of bed at 10 A.M. Physician notified. Incident report completed.'
- B. Client found on floor beside bed at 10 A.M. Alert and oriented times 3. States she slipped as she was standing up. Bruise (3 inches by 2 inches) on left hip. Denies pain. Dr. examined client. X-rays taken.'
- C. Client fell while getting out of bed. Seems okay. Charge nurse examined client. Doctor notified and incident report filed.'
- D. Found client on floor beside bed. Responds to questions. Red area on left hip. Notified charge nurse and physician.'
Correct Answer: B
Rationale: Accurate documentation includes specific details: time, client status, mechanism of fall, assessment findings (bruise size, orientation), and actions taken (physician notification, x-rays). This option is thorough and objective, unlike the others, which are vague or incomplete.
The nurse is developing a care plan for a client with severe anxiety. An appropriate outcome for the client is that within 4 days the client should:
- A. Have decreased anxiety.
- B. Talk to the nurse for 10 minutes.
- C. Sit quietly for 30 minutes.
- D. Develop an adaptive coping mechanism.
Correct Answer: B
Rationale: Outcome criteria need to be specific, measurable, and realistic. Talking for 10 minutes meets all of these conditions.