Nokea
The spouse of a client calls the nurse at the clinic and reports that the client is not feeling well and is concerned that something is seriously wrong. How should the nurse respond initially?
- A. Ask the spouse to further describe the client's symptoms
- B. Indicate that privacy rules prevent discussion of concerns with the spouse
- C. Offer a same-day appointment to the client
- D. Tell the spouse to have the client call the nurse
Correct Answer: A
Rationale: Asking for symptom details helps assess urgency without violating privacy, as the spouse initiated contact. Privacy rules don't preclude initial fact-gathering, but direct client contact or an appointment may follow based on severity.
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The nurse is reviewing the medical record for an adolescent client with major depressive disorder. Which of the following findings would be consistent with the condition? Select all that apply.
- A. often sleeps during class or after-school activities
- B. has received disciplinary action at school due to absenteeism and angry outbursts
- C. has unintentionally lost 8 lb (3.6 kg) over the past 3 weeks
- D. abruptly quit playing sports despite receiving previous athletic awards and trophies
- E. voices concern about the appearance of acne on the face
Correct Answer: A,B,C,D
Rationale: Excessive sleep, irritability (outbursts), weight loss, and loss of interest in activities (quitting sports) are hallmarks of depression. Acne concern is typical adolescent behavior, not specific to depression.
A client with renal failure has an order for erythropoietin (Epogen) to be given subcutaneously. The nurse should teach the client to report:
- A. Severe headache
- B. Slight nausea
- C. Decreased urination
- D. Itching
Correct Answer: A
Rationale: Erythropoietin can increase blood viscosity, raising the risk of hypertension or thrombosis, which may present as a severe headache. Slight nausea , decreased urination , and itching are less specific or urgent.
A home care client is scheduled for dialysis. He asks the nurse if he should take his antihypertensive medication before going for dialysis. How should the nurse respond?
- A. He should take all regularly scheduled medications.
- B. Antihypertensives should not be taken before dialysis because the blood pressure drops during dialysis.
- C. He should check with the physician because it varies from person to person.
- D. He should take it with him and take it if his blood pressure rises during the treatment.
Correct Answer: B
Rationale: Antihypertensives are often held before dialysis to prevent hypotension, as dialysis can lower blood pressure. Routine administration, physician checks, or conditional dosing are less appropriate.
The nurse has reinforced teaching with the parent of a pediatric client with newly diagnosed hemophilia A. Which of the following statements by the parent would indicate a correct understanding of the teaching? Select all that apply.
- A. I should avoid using icepacks if my child is injured.
- B. I should provide a high-fat, high-protein diet for my child.
- C. My child should wear emergency medical identification at all times.
- D. My child can participate in noncontact sports such as swimming.
- E. I should avoid giving my child medication containing aspirin.
Correct Answer: C,D,E
Rationale: Medical identification ensures prompt treatment in emergencies. Noncontact sports like swimming are safe. Aspirin increases bleeding risk and should be avoided. Ice packs are beneficial for injuries to reduce swelling, and diet doesn't require high-fat/protein for hemophilia management.
The charge nurse is observing the nurse apply a condom catheter for a client who is uncircumcised. The charge nurse should intervene if the nurse
- A. attaches the drainage tubing to a leg collection bag
- B. retracts the foreskin before applying the condom sheath
- C. assesses the condition of the penile skin prior to application
- D. leaves a 1- to 2-inch (2.5- to 5-cm) space at the tip of the condom
Correct Answer: B
Rationale: Retracting the foreskin before applying a condom catheter risks paraphimosis if not repositioned afterward, requiring intervention. Other actions are correct: attaching tubing, assessing skin, and leaving space prevent complications.