Nokea
A client who has been abusing alcohol and other drugs for six years. The nursing diagnosis is ineffective individual coping.
Which of the following nursing actions should take priority during the working stage of their relationship?
- A. Observe the client every half-hour to determine the extent of drug-seeking behavior.
- B. Monitor the intake of fluids, meals, and snacks to ensure adequate nutrition.
- C. Help the client obtain a sponsor through a 12-step group in the client's local area.
- D. Meet individually with the client to discuss the consequences of drug-using behavior and examine other options.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Are the assessments appropriate? No. Determine the outcome of the implementations. (1) assessment, important in the assessment phase of the relationship (2) assessment, important for a different nursing diagnosis (3) implementation, will be important in discharge planning (4) correct-implementation, describes the work of the interpersonal relationship with a chemically dependent client; goal is to get client to recognize problems the chemicals have caused and to learn new methods of solving problems
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Which of the following assessments would be a priority when documenting the nursing history of a two-year-old child?
- A. The child's rituals and routines at home.
- B. The child's understanding of hospitalization.
- C. The child's ability to be separated from the parents.
- D. The parent's methods for dealing with the child's temper tantrums.
Correct Answer: A
Rationale: during a crisis such as hospitalization, children are able to establish a sense of security through consistency of the rituals and routines from home
The nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following laboratory results should the nurse report immediately?
- A. PTT of 90 seconds.
- B. INR of 1.0.
- C. Platelet count of 150,000/mm^3.
- D. Hemoglobin of 13 g/dL.
Correct Answer: A
Rationale: A PTT of 90 seconds is above the therapeutic range (60–80 seconds), increasing bleeding risk. Options B, C, and D are normal.
A 22-year-old mother of a 4-year-old boy comes to the antepartal clinic. Her second pregnancy has just been confirmed.
During this initial visit, it MOST important for the nurse to
- A. assess the client's feelings about pregnancy, labor, and delivery.
- B. obtain a history of the client's last labor and delivery.
- C. determine how the client's 4-year-old feels about the pregnancy.
- D. identify the client's general health needs.
Correct Answer: D
Rationale: Strategy: Think about each answer choice. (1) important data, priority is the here and now (2) important data, but not priority for first visit (3) important data, need to deal with the mother's needs first (4) correct-optimal opportunity for preventative health maintenance
The nurse is caring for a client who is postoperative day 1 after a total abdominal hysterectomy. Which of the following findings should the nurse report immediately?
- A. Temperature of 100.4°F (38°C).
- B. Mild incisional pain.
- C. Scant vaginal bleeding.
- D. Urine output of 50 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.4°F suggests infection, a serious postoperative complication. Options B, C, and D are expected findings.
The nurse is caring for a client who is postoperative day 1 following a total knee replacement. Which of the following findings should the nurse report to the physician immediately?
- A. Pain at the surgical site rated 6/10.
- B. Swelling and warmth at the incision site.
- C. Urine output of 150 mL over 8 hours.
- D. Serosanguineous drainage on the dressing.
Correct Answer: B
Rationale: swelling and warmth may indicate infection or a deep vein thrombosis, which requires immediate attention