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When a client with alcohol dependency begins to talk about not having a problem with alcohol, the nurse should use which of the following approaches?
- A. Questioning the client about how much alcohol she drinks.
- B. Confronting the client with the fact that she was intoxicated 2 days ago.
- C. Pointing out how alcohol has gotten her into trouble.
- D. Listening to what the client states and then asking her how she plans to stay sober.
Correct Answer: D
Rationale: This approach uses therapeutic communication, acknowledging the client's perspective and encouraging problem-solving, which is effective for addressing denial in alcohol dependency.
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The nurse is visiting a client who has been prescribed topical clotrimazole. The nurse should educate the client to the fact that this medication will alleviate which condition?
- A. Pain
- B. Rash
- C. Fever
- D. Sneezing
Correct Answer: B
Rationale: Clotrimazole is a topical antifungal used in the treatment of cutaneous fungal infections and will alleviate an associated rash. The nurse teaches the client that it is used for this purpose. It is not used for pain, sneezing, or fever.
The nurse judges that the parent of a 9-month-old infant in a hip spica cast understands how to feed the child when the parent states which of the following?
- A. I can lay my child flat and feed that way.'
- B. I'll raise my child's head up and leave the hips and legs on a pillow.'
- C. I can borrow a special feeding table to use.'
- D. It will take two of us, one to hold and one to feed.'
Correct Answer: B
Rationale: Raising the infant's head while keeping the hips and legs supported minimizes the risk of aspiration and accommodates the hip spica cast's restrictions. Laying flat increases aspiration risk, and the other options are impractical or unnecessary.
The nurse is caring for a client with a history of burns. Which of the following complications should the nurse monitor for in the acute phase?
- A. Hypovolemia.
- B. Hypernatremia.
- C. Hypoglycemia.
- D. Respiratory alkalosis.
Correct Answer: A
Rationale: Hypovolemia is a major complication in the acute phase of burns due to fluid loss.
The nurse is teaching a client with a new diagnosis of type 1 diabetes about sick day management. Which of the following instructions should be included? Select all that apply.
- A. Continue taking insulin.
- B. Monitor blood glucose frequently.
- C. Avoid eating solid foods.
- D. Drink plenty of fluids.
- E. Contact the healthcare provider if vomiting persists.
Correct Answer: A, B, D, E
Rationale: Continuing insulin, frequent glucose monitoring, fluid intake, and contacting the provider prevent complications during illness.
You measure your 2 year old client's vital signs as: • Respiratory rate: 32 breaths per minute • Pulse: 110 beats per minute • Blood pressure: 55/82. The mother asks you if these vital signs are normal. You should respond to this mother's question by stating:
- A. The respiratory rate is a little too fast but the other vital signs are normal.'
- B. The pulse rate is a little too fast but the other vital signs are normal.'
- C. The blood pressure is a little low but the other vital signs are normal.'
- D. All of these vital signs are normal for a child that is 2 years of age.'
Correct Answer: C
Rationale: For a 2-year-old, normal ranges are approximately: respiratory rate 20-30 breaths/min, pulse 80-130 beats/min, blood pressure ~90/55 mmHg. The blood pressure (55/82) is low (systolic is below normal), while the respiratory rate and pulse are within or slightly above normal ranges.