Nokea
A 33-year-old woman comes to the local outpatient clinic for complaints of dizziness and palpitations. Her physical exam and laboratory results are normal. She reports that the company she owns is on the verge of bankruptcy.
Which of the following responses, if made to the client by the nurse, would be BEST?
- A. When did you first notice these symptoms?'
- B. Have you shared this information with anyone?'
- C. Are you concerned about your financial difficulties?'
- D. Would you like to discuss your situation with me?'
Correct Answer: A
Rationale: Strategy: 'BEST' indicates there may be more than one correct response. Remember therapeutic communication. (1) correct-open-ended question, encourages client to discuss when problems occurred (2) yes/no question, nontherapeutic, doesn't encourage discussion of symptoms (3) yes/no question, nontherapeutic, too confrontational, does not encourage discussion (4) yes/no question, nontherapeutic
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The nurse has just returned to the desk and has four phone messages to return.
- A. Which phone message should the nurse return first?
- B. A woman in her first trimester of pregnancy complaining of heartburn.
- C. A man complaining of heartburn that radiates to his jaw.
- D. A woman complaining of hot flashes and difficulty sleeping.
- E. A boy complaining of knee pain after playing basketball.
Correct Answer: B
Rationale: Heartburn radiating to the jaw in a man indicates possible chest pain, which could be a symptom of a myocardial infarction, a life-threatening condition requiring immediate medical attention. The other conditions (pregnancy-related heartburn, menopausal symptoms, and knee pain) are less urgent and can be addressed after ruling out a cardiac emergency.
A child is admitted in sickle cell crisis. Which factor in the child's history is most likely related to the onset of the crisis?
- A. The child just completed final exams at school.
- B. The child ran a marathon yesterday.
- C. The child recently had a cold.
- D. The child received a hepatitis A immunization two weeks ago.
Correct Answer: C
Rationale: Infections, like a recent cold, can trigger sickle cell crisis by increasing oxygen demand and causing dehydration, leading to sickling of red blood cells.
A client returns from surgery after an open reduction of a femur fracture. There is a small bloodstain on the cast. Four hours later, the nurse observes that the stain has doubled in size. What is the best action for the nurse to take?
- A. Call the health care provider
- B. Access the use of a window in the cast
- C. Simply record the findings in the nurse's notes only
- D. Outline the spot with a pencil and note the time and date on the cast
Correct Answer: D
Rationale: Outline the spot with a pencil and note the time and date on the cast. This is a good way to assess the amount of bleeding over a period of time. The bleeding does not appear to be excessive and some bleeding is expected with this type of surgery. The bleeding should also be documented in the nurse's notes.
A client is discharged following hospitalization for congestive heart failure. The nurse teaching the family suggests they encourage the client to rest frequently in which of the following positions?
- A. High Fowler's
- B. Supine
- C. Left lateral
- D. Low Fowler's
Correct Answer: A
Rationale: High Fowler's. This position decreases cardiac workload and facilitates breathing.
The nurse is assessing the nursing care unit in a long-term facility for fire hazards. Which finding is the greatest fire hazard?
- A. Some of the nurses and nursing assistants smoke in the restroom.
- B. There are several cardboard boxes and cleaning supplies stored in the room with the emergency oxygen supply.
- C. Several residents have dust under their beds.
- D. Two of the residents have closets that are stuffed full of photo albums and sewing supplies.
Correct Answer: B
Rationale: Storing flammable materials near oxygen increases fire risk, as oxygen supports combustion. Smoking, dust, or cluttered closets are less hazardous.