Nokea
Which client is most at risk for methicillin-resistant Staphylococcus aureus infection?
- A. 15-year-old student athlete in the emergency department with a closed femur fracture
- B. 46-year-old client on the medical-surgical unit after a laparoscopic appendectomy
- C. 72-year-old client who received a permanent pacemaker 24 hours ago
- D. 80-year-old client with a hemodialysis catheter who lives in a long-term care facility
Correct Answer: D
Rationale: The 80-year-old with a hemodialysis catheter in a long-term care facility (D) is at highest risk for MRSA due to invasive devices, frequent healthcare exposure, and communal living. Others (A, B, C) have lower risk profiles.
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The nurse is talking with a client with stable angina who has a prescription for sublingual nitroglycerin. Which of the following statements by the client would require follow-up?
- A. I shall sit down if possible before taking this medication to prevent dizziness.
- B. I may experience flushing or a headache when taking this medication.
- C. I will avoid taking the medication with grapefruit juice.
Correct Answer: C
Rationale: Nitroglycerin is not contraindicated with grapefruit juice (C), indicating a misunderstanding. Sitting down (A) prevents falls from hypotension, and flushing/headache (B) are expected side effects, both correct.
The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?
- A. Repeatedly checking that the door is locked
- B. Verbalized suspicions about thefts
- C. Preference for consistent caregivers
- D. Repetitive, involuntary movements
Correct Answer: A
Rationale: Behaviors that are repeated are symptomatic of obsessive-compulsive disorders. These behaviors, performed to reduce feelings of anxiety, often interfere with normal function and employment.
The emergency room nurse admits a child who experienced a seizure at school. The parent comments that this is the first occurrence and denies any family history of epilepsy. What is the best response by the nurse?
- A. Do not worry. Epilepsy can be treated with medications.
- B. The seizure may or may not mean your child has epilepsy.
- C. Since this was the first convulsion, it may not happen again.
- D. Long term treatment will prevent future seizures.
Correct Answer: B
Rationale: The seizure may or may not mean your child has epilepsy. A single seizure has multiple potential causes, not necessarily epilepsy.
The practical nurse on the mental health unit is planning care with the registered nurse. Which client should be seen first?
- A. Client with bulimia nervosa who has been in the restroom for the past hour since breakfast
- B. Client with major depressive disorder who has suicidal ideation with a plan and is on one-to-one observation
- C. Client with obsessive-compulsive disorder who refuses to attend group therapy because it interrupts handwashing ritual
- D. Client with schizophrenia who is experiencing delusions and is pacing the room and yelling at caregivers
Correct Answer: B
Rationale: Suicidal ideation with a plan (B) poses an immediate safety risk, requiring urgent assessment despite one-to-one observation. Bulimia (A) and schizophrenia (D) behaviors need monitoring but are less acute. OCD refusal (C) is a lower priority, as it does not indicate immediate harm.
The client complains of frequent insomnia affecting her ability to rest well. Which of the following factors or lifestyle choices in her assessment history most likely contributes to her inability to sleep?
- A. Having a slight snack at bedtime
- B. Heart disease prevention of one baby aspirin each day
- C. Reading in bed prior to going to sleep
- D. Smoking 1½ packs of filtered cigarettes each day
Correct Answer: D
Rationale: Nicotine in cigarettes is a stimulant, disrupting sleep and likely contributing to insomnia, unlike snacks, aspirin, or reading.