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Which of the following is the best way for the nurse to begin the preoperative interview?
- A. Walk in the client's room and ask, 'Are you Mrs. Smith?'
- B. Walk in the client's room, sit down, and take the client's blood pressure.
- C. Walk in the client's room, sit down, maintain eye contact, and introduce yourself.
- D. Walk in the client's room, and ask the client her name.
Correct Answer: C
Rationale: Introducing oneself while maintaining eye contact and sitting down establishes rapport and trust, creating a therapeutic environment for the interview. This approach prioritizes patient comfort and communication.
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When discussing recent onset of feelings of sadness and depression in a client with hypothyroidism, the nurse should inform the client that these feelings are:
- A. The effects of thyroid hormone replacement therapy and will diminish over time.
- B. Related to thyroid hormone replacement therapy and will not diminish over time.
- C. A normal part of having a chronic illness.
- D. Most likely related to low thyroid hormone levels and will improve with treatment.
Correct Answer: D
Rationale: Low thyroid hormone levels in hypothyroidism can cause depression and sadness, which typically improve with thyroid hormone replacement therapy.
The nurse is instructing a client who is at risk for peripheral vascular disease how to use knee-length elastic stockings (support hose). The teaching plan should include which of the following? Check all that apply.
- A. Apply the elastic stockings in the morning
- B. Remove the stockings if swelling occurs
- C. Apply the stockings while in bed
- D. Once the stockings have been pulled over the calf, roll the remaining stocking down to make a cuff
- E. Keep the stockings in place for 48 hours and reapply using a clean pair of stockings
Correct Answer: A,C
Rationale: Rationales: A) Applying elastic stockings in the morning before edema worsens helps promote venous return. C) Applying them while in bed (before standing) minimizes swelling and eases application. B) Removing stockings for swelling requires medical evaluation, not automatic removal. D) Rolling down to form a cuff creates pressure points, impairing circulation. E) Stockings should be removed daily for skin inspection and hygiene, not kept on for 48 hours.
The nurse is caring for a client reporting an abrupt onset of severe pain associated with metastatic cancer. Which prescription should the nurse plan to administer?
- A. fentanyl via transdermal patch
- B. pregabalin
- C. ketorolac
- D. hydromorphone
Correct Answer: D
Rationale: Hydromorphone is appropriate for rapid relief of severe, acute cancer pain due to its fast-acting opioid properties.
When conducting a health history with a female client with thyrotoxicosis, the nurse should ask about which of the following changes in the menstrual cycle?
- A. Dysmenorrhea.
- B. Metrorrhagia.
- C. Oligomenorrhea.
- D. Menorrhagia.
Correct Answer: C
Rationale: Thyrotoxicosis increases metabolism, which can lead to decreased menstrual flow or oligomenorrhea (infrequent menstruation). Dysmenorrhea (painful periods), metrorrhagia (irregular bleeding), and menorrhagia (heavy bleeding) are less commonly associated with thyrotoxicosis.
Which of the following is not a realistic outcome to establish with a client who has multiple sclerosis (MS)? The client will:
- A. Develop joint mobility.
- B. Develop muscle strength.
- C. Develop cognition.
- D. Develop mood elevation.
Correct Answer: C
Rationale: Developing cognition is not realistic, as MS can cause cognitive decline that is not typically reversible. Improving mobility, strength, and mood are achievable with therapy and support.