Nokea
When counseling a 6 year-old who is experiencing enuresis, what must the nurse understand about the pathophysiological basis of this disorder?
- A. It has no clear etiology
- B. Enuresis may be associated with sleep phobia
- C. It has a definite genetic link
- D. Enuresis is a sign of willful misbehavior
Correct Answer: A
Rationale: It has no clear etiology. Enuresis has multiple contributing factors, but no single definitive cause has been established.
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The nurse has just received the shift report. Which one of the following clients should be seen first?
- A. A 14-year-old one day post-appendectomy with a WBC of 6500
- B. A 5-year-old three days post-fracture of the right tibia with a temperature of 101° Fahrenheit
- C. An 11-month-old admitted during the previous shift with dehydration and a hematocrit of 40
- D. An 8-week-old admitted four hours earlier with sub-sternal retractions and an oxygen saturation of 90%
Correct Answer: D
Rationale: Answer D is correct. There is nothing in answer A that indicates the client is unstable. Answer B is a good choice, but the client three days post-fracture may have a slight temperature, so he should be seen second. Answer C is also a good choice, but if the infant with dehydration is stable, the 8-week-old with respiratory distress (sub-sternal retractions and low oxygen saturation) is the most critical and should be seen first.
A client admitted to the medical surgical unit was recently weaned from the mechanical ventilator and an IV infusion of lorazepam. The client has been alert and oriented for 24 hours but is now experiencing confusion. The practical nurse assists the registered nurse with the evaluation of new-onset confusion by assessing the client's sense of place and time, difficulty focusing, short-term memory loss, and increasing lethargy. The practical nurse suspects which condition in this client?
- A. Amnesia
- B. Delirium
- C. Dementia
- D. Psychosis
Correct Answer: B
Rationale: New-onset confusion with disorientation, difficulty focusing, memory loss, and lethargy post-ventilation and lorazepam suggests delirium , often seen in ICU patients due to medication withdrawal or critical illness. Amnesia , dementia , and psychosis have different presentations.
An adult who had a laryngectomy is ready for discharge. What question is it essential for the nurse to ask the client before discharge?
- A. How many people live in your household?
- B. Does your home have working smoke detectors?
- C. Do you cook with gas or electricity?
- D. When is your doctor's appointment?
Correct Answer: B
Rationale: Smoke detectors are critical post-laryngectomy, as impaired speech and potential airway issues increase fire safety risks, making this a priority discharge question.
When walking past a client's room, the nurse hears 1 unlicensed assistive personnel (UAP) talking to another UAP. Which statement requires follow-up intervention?
- A. If we work together we can get all of the client care completed.
- B. Since I am late for lunch, would you do this one client's glucose test?
- C. If we client seems confused, we need to watch another closely.
- D. I'll come back and make the bed after I go to the lab.
Correct Answer: B
Rationale: Only the RN and PN can delegate to UAPs. One UAP cannot delegate a task to another UAP. The RN or PN is legally accountable for the nursing care.
The client is scheduled for a paracentesis. What should the nurse expect to do prior to the procedure?
- A. Insert an indwelling catheter
- B. Have the client void
- C. Keep the client NPO
- D. Administer an enema
Correct Answer: B
Rationale: Having the client void before paracentesis prevents bladder puncture during the procedure. Catheter insertion, NPO status, or enemas are not typically required.