Nokea
An eight-year-old receiving chemotherapy for six months.
Which of the following responses by the nurse is BEST?
- A. Are you afraid of dying?'
- B. Why do you ask that question?'
- C. Only God knows that answer.'
- D. We won't leave you alone.'
Correct Answer: A
Rationale: Strategy: Remember therapeutic communication. (1) correct-encourages ventilation of thoughts and feelings regarding the concern (2) inappropriate (3) ignores the child's concern with dying (4) ignores the child's concern with dying
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The nurse is caring for a client with a history of bipolar disorder who is receiving valproic acid (Depakote) 500 mg PO bid. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Liver enzymes elevated to twice normal.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: Elevated liver enzymes suggest hepatotoxicity, a serious side effect of valproic acid, requiring immediate evaluation to prevent liver failure. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and hemoglobin 13 g/dL do not indicate complications.
A client admitted with tuberculosis asks the nurse how long he will have to take his prescription for INH. The best answer for the nurse to give the client is:
- A. It depends on the type of tuberculosis you have.'
- B. You will need to take the INH for approximately 6 months.'
- C. After about 6 weeks, the doctor will discontinue the medication.'
- D. You will remain on INH for an indefinite time period.'
Correct Answer: B
Rationale: INH (isoniazid) treatment for active tuberculosis typically lasts 6-9 months. Six weeks is too short, and indefinite treatment is incorrect.
A nurse performing actions that would be considered negligence.
Which of the following actions, if performed by the nurse, would be considered negligence?
- A. Obtaining a Guthrie Blood Test on a four-day-old infant.
- B. Massaging lotion on the abdomen of a three-year-old diagnosed with Wilm's tumor.
- C. Instructing a five-year-old asthmatic to blow on a pinwheel.
- D. Playing kickball with a 10-year-old with juvenile arthritis (JA).
Correct Answer: B
Rationale: Strategy: 'Would be considered negligence' indicates an incorrect action. (1) obtain after ingestion of protein, no later than 7 days after delivery (2) correct-manipulation of mass may cause dissemination of cancer cells (3) this exercise extends expiratory time and increases expiratory pressure (4) excellent moving and stretching exercise
A bipolar patient refuses to put down the mop that he is swinging to threaten other patients and staff.
What information is MOST important for the nurse to consider before administering a PRN IM dose of lorazepam (Ativan)?
- A. The patient is harmful to himself.
- B. The patient is psychotic.
- C. A restrictive intervention failed.
- D. The patient is harmful to others.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) use the least restrictive interventions in ascending order (2) use the least restrictive interventions in ascending order (3) correct-use the least restrictive interventions in ascending order (4) use the least restrictive interventions in ascending order
During the admission assessment on a client with chronic bilateral glaucoma, which statement by the client would the nurse anticipate since it is associated with this problem?
- A. I have constant blurred vision.
- B. I can't see on my left side.
- C. I have to turn my head to see my room.
- D. I have specks floating in my eyes.
Correct Answer: C
Rationale: I have to turn my head to see my room. Intraocular pressure becomes elevated, producing a progressive loss of the peripheral visual field in the affected eye.