Nokea
What would be the nurse's best response to the client's expressed feelings of isolation as a result of having hepatitis?
- A. Don't worry. It's normal to feel that way.'
- B. Your friends are probably afraid of contracting hepatitis from you.'
- C. I'm sure you're imagining that!'
- D. Tell me more about your feelings of isolation.'
Correct Answer: D
Rationale: Encouraging the client to express feelings (D) fosters therapeutic communication and addresses emotional needs. Dismissing feelings (A, C) or assuming others' fears (B) is non-therapeutic and unhelpful.
You may also like to solve these questions
Several clients come to the emergency department with suspected contamination by the Ebola virus. What should the nurse do? Select all that apply.
- A. Call in extra staff to assist with the possibility of more clients with the same condition.
- B. Isolate all the suspected clients in the emergency department in one area.
- C. Call housekeeping for diluted household bleach.
- D. Restrict visitors from the emergency department.
- E. Quarantine all contacts.
Correct Answer: A,B,C,D,E
Rationale: Ebola requires comprehensive measures: extra staff for surge capacity, isolation to prevent spread, bleach for disinfection, visitor restrictions, and contact quarantine to control the outbreak.
In the acute phase of burn injury, which pain medication would most likely be given to the client to decrease the perception of the pain?
- A. Oral analgesics such as ibuprofen (Motrin) or acetaminophen (Tylenol).
- B. Intravenous opioids.
- C. Intramuscular opioids.
- D. Oral antianxiety agents such as lorazepam (Ativan).
Correct Answer: B
Rationale: Intravenous opioids are preferred in the acute phase for rapid, effective pain relief due to severe burn pain and potential impaired oral absorption.
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion?
- A. Suction the airway.
- B. Hyperoxygenate.
- C. Suction the mouth.
- D. Provide sedation.
Correct Answer: B,D,A,C
Rationale: The correct order is: 1) Hyperoxygenate to prevent hypoxia (B); 2) Provide sedation to reduce agitation and ICP spikes (D); 3) Suction the airway to clear secretions (A); 4) Suction the mouth to remove residual secretions (C). This sequence minimizes ICP increases and ensures oxygenation.
The nurse is to administer midazolam (Versed) 2.5 mg. The medication is available in a 5 mg/mL vial. The nurse should administer ___ mL.
Correct Answer: 0.5
Rationale: To administer 2.5 mg from a 5 mg/mL vial, calculate: 2.5 mg ÷ 5 mg/mL = 0.5 mL. This is a calculation question, not multiple-choice, but included as per instructions.
The nurse is conducting a postoperative assessment of a client on the first day after renal surgery. Which of the following findings would be most important for the nurse to report to the physician?
- A. Temperature, 99.8°F (37.7°C).
- B. Urine output, 20 mL/hour.
- C. Absence of bowel sounds.
- D. A 2€ x 2€ area of serosanguineous drainage on the flank dressing.
Correct Answer: B
Rationale: Urine output of 20 mL/hour is critically low, indicating potential renal compromise or obstruction, requiring immediate physician notification.