Nokea
Which of the following is an appropriate nursing goal for a client at risk for nutritional problems?
- A. provide oxygen
- B. promote healthy nutritional practices
- C. treat complications of malnutrition
- D. increase weight
Correct Answer: B
Rationale: Promoting healthy nutritional practices is an appropriate nursing goal for a client at risk for nutritional problems. Choice A is incorrect because it is a nursing intervention, not a goal statement. Choice C is incorrect because it is a therapeutic treatment. Choice D is incorrect because weight gain is an appropriate goal only if the client is underweight.
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Pain tolerance in an elderly client with cancer should:
- A. Stay the same.
- B. Decrease.
- C. Increase.
- D. Cancer should have no effect on pain tolerance for an elderly client.
Correct Answer: B
Rationale: There is potential for a lowered pain tolerance to exist with diminished adaptative capacity.
Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except:
- A. tolerance.
- B. constipation.
- C. sedation.
- D. addiction.
Correct Answer: D
Rationale: Addiction is not of primary concern when treating the pain of terminally ill clients. Clients with cancer who are taking opioid analgesics can develop tolerance, constipation, and sedation.
Mr. H. is upset regarding being in the hospital for another day because he states it costs too much. The rights he is likely to demand include all of the following except:
- A. the right to examine and question the bill
- B. the right to reasonable response to requests
- C. the right to refuse treatment
- D. the right to confidentiality
Correct Answer: D
Rationale: The client's concern about costs suggests he may demand to examine the bill, expect reasonable responses, or refuse treatment. Confidentiality, while a right, is unrelated to his stated financial concerns and is not suggested to be breached.
A nurse is working in a pediatric clinic and a mother brings in her 13 month old child who has Down Syndrome. The mother reports, 'My child's muscles feel weak and he isn't moving well. My RN friend checked his reflexes and she said they are diminished.' Which of the following actions should the nurse take first?
- A. Contact the physician immediately
- B. Have the patient go to X-ray for a c-spine work-up.
- C. Start an IV on the patient
- D. Position the child's neck in a neutral position
Correct Answer: D
Rationale: An atlanto-axial dislocation may have occurred, common in Down Syndrome. Positioning the child's neck in a neutral c-spine posture is the first step to prevent further injury, followed by contacting the doctor.
A 17-year-old female was raped by a young man in her neighborhood. She is in the Emergency Department for evaluation and tests. After the procedure is completed, a rape crisis counselor (nurse specialist) talks to the client in a conference room regarding the rape. Implementing counseling by the nurse specialist for the raped victim represents:
- A. assessment.
- B. crisis intervention.
- C. empathetic concern.
- D. unwarranted intrusion.
Correct Answer: B
Rationale: Choice 2 is part of the Crisis Intervention Model. Counseling by a nurse specialist at the time of a stressful event (rape) can strengthen the client's coping. A nurse specialist in rape crisis intervention is educationally prepared in counseling and crisis intervention specific to rape victims.