Nokea
Which of the following nursing diagnoses should the nurse implement as part of the long-term care for a child with hemophilia?
- A. Deficient knowledge
- B. Risk for injury
- C. Situational low self-esteem
- D. Acute pain
Correct Answer: B
Rationale: Risk for injury is a priority nursing diagnosis for a child with hemophilia due to the risk of bleeding from minor trauma. Other diagnoses may apply but are less critical long-term.
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The nurse is caring for a client with a history of deep vein thrombosis (DVT). Which of the following laboratory values should the nurse monitor?
- A. Activated partial thromboplastin time (aPTT).
- B. Prothrombin time (PT).
- C. International normalized ratio (INR).
- D. D-dimer.
Correct Answer: A, D
Rationale: aPTT monitors heparin therapy, and D-dimer indicates clot presence in DVT.
A mother reports to the nurse that she cannot afford the antibiotic azithromycin (Zithromax), which was ordered by the physician for her toddler's ear infection. Which of the following is the most appropriate action by the nurse?
- A. Instruct the mother on the importance of the medication
- B. Ask the mother if she knows anyone who could loan her the money
- C. Confer with the physician about whether a less expensive drug could be ordered
- D. Consult with the social worker
Correct Answer: C
Rationale: Conferring with the physician to explore a less expensive alternative medication addresses the mother's financial concern while ensuring treatment. Instructing on importance doesn't solve affordability, asking about loans is inappropriate, and a social worker may help later but isn't the first step.
A client has been prescribed transcutaneous electrical nerve stimulation (TENS) by the primary health care provider for the relief of chronic pain. Which statement by the client would indicate to the nurse a need for further teaching regarding this pain relief measure?
- A. I understand that this will help relieve the pain.
- B. This unit will eliminate the need for taking so many pain medications.
- C. I am not real happy that I have to stay in the hospital for this treatment.
- D. I am not sure that I am going to like those electrodes attached to my skin.
Correct Answer: C
Rationale: It is not necessary for the client to remain in the hospital for this treatment. The TENS unit is a portable unit, and the client controls the system for relieving pain and reducing the need for analgesics. It is attached to the skin of the body by electrodes.
A registered nurse (RN) is supervising a licensed practical nurse (LPN) providing care to a client with end-stage heart failure. The client is withdrawn, is reluctant to talk, and shows little interest in participating in hygienic care or activities. Which statement by the LPN to the client indicates that the LPN needs further teaching in the use of therapeutic communication skills?
- A. You are very quiet today.
- B. What are your feelings right now?
- C. Why don't you feel like getting up?
- D. Tell me more about your difficulty with sleeping at night.
Correct Answer: C
Rationale: When a 'why' question is made to the client, an explanation for feelings and behaviors is requested, and the client may not know the reason. Requesting an explanation is a nontherapeutic communication technique. In option 1, the LPN is using the therapeutic communication technique of acknowledging the client's behavior. In option 2, the LPN is encouraging identification of emotions or feelings. In option 4, the LPN is using the therapeutic communication technique of exploring, which is asking the client to describe something in more detail or to discuss it more fully.
A client with a history of breast cancer is prescribed tamoxifen (Nolvadex). Which side effect should the nurse teach the client to report?
- A. Hot flashes
- B. Weight gain
- C. Vaginal bleeding
- D. Fatigue
Correct Answer: C
Rationale: Vaginal bleeding may indicate endometrial hyperplasia or cancer, a serious side effect of tamoxifen requiring immediate reporting.