Nokea
A 75-year-old man following a right total hip replacement. The nurse's notes indicate that since the surgery the patient has become disoriented and confused at night. One evening as the nurse prepares the patient for sleep, the patient glances to his left and says, 'Oh, you think so?' and starts to laugh.
Which of the following responses by the nurse is the BEST?
- A. Do you hear voices talking to you?'
- B. Tell me why you are laughing so I can laugh too.'
- C. What is it that you find amusing?'
- D. I notice you're laughing.'
Correct Answer: D
Rationale: Strategy: Remember therapeutic communication. (1) yes/no question, may make client defensive and block communication (2) feeds into client's altered-reality state, nurse should suspect a hallucination (3) confrontation would block communication (4) correct-therapeutic statement of client's nonverbal communication
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The nurse working in a surgeon's office receives all of the following messages from the answering service. Which client should be called back first?
- A. An adult who had an inguinal hernia repair yesterday states that he is having trouble urinating.
- B. An adult who had an appendectomy yesterday says the pain medication makes her sleepy.
- C. An adult who had abdominal surgery two weeks ago wants to know if she can drive a car.
- D. An adult who had a laparoscopic cholecystectomy two days ago says the adhesive bands fell off the incisions.
Correct Answer: A
Rationale: Difficulty urinating post-hernia repair may indicate urinary retention, a potential complication requiring urgent attention. Other issues are less immediate.
A 3 year-old child is brought to the clinic by his grandmother to be seen for 'scratching his bottom and wetting the bed at night.' Based on these complaints, the nurse would initially assess for which problem?
- A. allergies
- B. scabies
- C. regression
- D. pinworms
Correct Answer: D
Rationale: Pinworms are a common cause of anal itching and can contribute to bed-wetting in children due to discomfort. The nurse should assess for signs of pinworm infection, such as observing the anal area for worms or performing a tape test.
An involuntary psychiatric patient asks the nurse to mail his letter to the President. He states that the letter will make the President regret his actions to prevent homosexuals from serving in the military. Which of the following responses by the nurse is BEST?
- A. Accept the letter and place it in the patient's medical record.
- B. Read the patient's letter and decide if it is appropriate to mail.
- C. Call the patient's psychiatrist and inform him of the letter.
- D. Discourage the patient from sending the letter, but mail it if patient insists.
Correct Answer: D
Rationale: Mailing the letter respects the patient’s communication rights while addressing potential concerns. Options A, B, and C violate autonomy or privacy.
The nurse is caring for a client with a history of Parkinson’s disease.
- A. Which intervention is most effective for improving mobility in a client with Parkinson’s disease?
- B. Encourage a high-fiber diet.
- C. Administer levodopa on an empty stomach.
- D. Restrict physical activity to prevent falls.
- E. Apply warm compresses to joints.
Correct Answer: B
Rationale: Administering levodopa on an empty stomach enhances absorption, improving motor function in Parkinson’s disease. High-fiber diets prevent constipation, activity is encouraged, and compresses are ineffective for mobility.
To minimize the side effects of a DPT immunization for a six-month-old.
The nurse should instruct the parents to
- A. give the child an alcohol bath for an elevated temperature.
- B. administer antipyretics for discomfort, irritability, and fever.
- C. place an ice bag on the child's leg for one hour.
- D. check the child's temperature every four hours for three days.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Is the assessment appropriate? No. Determine the outcome of each implementation. Is it desired? (1) implementation, uncomfortable and unnecessary (2) correct-implementation, antipyretics relieve the combination of side effects (3) implementation, dangerous to both skin integrity and overall temperature control (4) assessment, unnecessary unless indicated for another reason