Nokea
An adult woman is admitted to an acute locked psychiatric unit one month prior to an election.
Which of the following responses by the nurse is BEST?
- A. You are not eligible to vote because you are a psychiatric patient.'
- B. I'll make the appropriate arrangements for you to vote.'
- C. You may vote only if you are discharged by Election Day.'
- D. I'll contact the Election Board to see if you are registered to vote.'
Correct Answer: B
Rationale: Strategy: Determine the outcome of each answer choice. (1) psychiatric patients do not forfeit their constitutional rights (2) correct-patient can vote by absentee ballot (3) can vote by absentee ballot (4) not the nurse's responsibility
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A client has been diagnosed with metastatic cancer with a poor prognosis. Recently, the client has complained of increased pain and is less communicative, very irritable, and anorexic.
Which of the following nursing goals should be a priority at this time?
- A. Encourage client to talk about the possibility of dying.
- B. Provide pain assessment and effective pain management.
- C. Manage nutrition and hydration.
- D. Verify that the physician has discussed the prognosis with the family.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will be difficult if client's pain is not adequately controlled (2) correct-comprehensive and regular pain assessment/management is necessary to facilitate client's ability to maintain comfort, which may enable him to verbalize his feelings (3) important, but will be difficult if client's pain is not adequately controlled (4) not highest priority
A client chief complaint in a nursing health history.
Which of the following is an example of a properly recorded client chief complaint in a nursing health history?
- A. Complains of midepigastric discomfort with flatus after meals.'
- B. Area above umbilicus appears to be painful and tender to palpation.'
- C. My stomach hurts after dinner every night.'
- D. Rebound tenderness present in mid-to-upper abdominal area.'
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) incorrectly stated (2) objective finding (3) correct-chief complaint should be recorded using the client's own words (4) objective finding
A 22-year-old woman comes to the hospital at term in the early stages of labor. A diagnosis of complete placenta previa is made.
It would be MOST important for the nurse to take which of the following actions?
- A. Start an IV of terbutaline (Brethine) and monitor the patient's vital signs closely.
- B. Prepare the patient for an immediate cesarean section.
- C. Maintain the patient on bedrest until spontaneous vaginal delivery is achieved.
- D. Monitor the patient's length and duration of contractions.
Correct Answer: B
Rationale: Strategy: Answers are both assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. Is it desired? (1) implementation, Brethine used to delay delivery in preterm labor (2) correct-implementation, cannot deliver vaginally (3) implementation, cannot deliver vaginally (4) assessment, cannot deliver vaginally, cesarean section must be performed
A child is admitted with acute glomerulonephritis. Which finding in the client's history is most consistent with the diagnosis?
- A. A recent tick bite
- B. Pharyngitis two weeks ago
- C. A mosquito bite last week
- D. Ingestion of foods high in uric acid
Correct Answer: B
Rationale: Acute glomerulonephritis is often post-streptococcal, following pharyngitis by 1-3 weeks, due to immune complex deposition in glomeruli. Tick bites, mosquito bites, or uric acid are unrelated.
The physician prescribes estrogen (Premarin) 0.625 mg daily for a 43-year-old woman. The nurse knows which of the following symptoms is a common initial side effect of this medication?
- A. Nausea.
- B. Visual disturbances.
- C. Tinnitus.
- D. Ataxia.
Correct Answer: A
Rationale: common at breakfast time; will subside after weeks of medication use; take after eating to reduce incidence