Nokea
Following hip replacement surgery, an elderly client is ordered to begin ambulation with a walker.
Which of the following statements by the nurse is BEST?
- A. Sit in a low chair for ease in getting up to use the walker.
- B. Make sure rubber caps are in place on all four legs of the walker.
- C. You will begin weight-bearing on the affected hip soon.
- D. Practice tying your own shoes before you begin ambulating.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks (2) correct-intact rubber caps should be present on walker legs to prevent accidents (3) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks (4) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks
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A 6-year-old child is seen in the physician's office. His mother tells you that for the last few weeks, the child has been urinating frequently, drinking and eating a lot. The nurse determines that the urine specific gravity is 1.004. The child is afebrile. What tests does the nurse expect to be ordered for this client at this time?
- A. CBC with differential
- B. Urine and finger stick glucose tests
- C. Intravenous pyelogram.
- D. Urine for culture and sensitivity
Correct Answer: B
Rationale: Polyuria, polydipsia, polyphagia, and low urine specific gravity (1.004) suggest diabetes mellitus; urine and finger stick glucose tests confirm hyperglycemia. CBC, IVP, or culture are less relevant.
A multipara client who delivered a female infant one hour ago. The nurse observes that the client's breasts are soft; the uterus is boggy, to the right of the midline, and 2 cm below the umbilicus; moderate lochia rubra.
It is MOST important for the nurse to take which of the following actions?
- A. Perform a straight catheterization.
- B. Offer the client the bedpan.
- C. Put the baby to breast.
- D. Massage the uterine fundus.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) encourage the client to void before catheterizing (2) correct-boggy uterus deviated to right indicates full bladder, encourage client to void (3) will increase uterine tone, but the problem is a full bladder (4) findings indicate a full bladder
The nurse is performing discharge teaching for a client with Addison’s disease.
- A. What is the most important instruction for a client with Addison’s disease?
- B. Signs and symptoms of infection.
- C. Fluid and electrolyte balance.
- D. Seizure precautions.
- E. Steroid replacement.
Correct Answer: D
Rationale: Steroid replacement is critical for Addison’s disease to manage adrenal insufficiency and prevent life-threatening crises. Infection, fluid balance, and seizures are secondary concerns compared to ensuring steroid therapy adherence.
The nurse is caring for a client with a history of breast cancer.
- A. Which symptom should the nurse report immediately for a client with a history of breast cancer?
- B. Mild fatigue after chemotherapy.
- C. A new lump in the axillary region.
- D. Occasional nausea.
- E. Hair loss.
Correct Answer: B
Rationale: A new lump in the axillary region may indicate lymph node metastasis, requiring immediate evaluation. Fatigue, nausea, and hair loss are expected chemotherapy side effects.
At an inpatient psychiatric unit, a 40-year-old woman insists on staying in her room and repeatedly comments to the nurse: 'Special agents are here. Maybe you are one.'
Which of the following responses, if made by the nurse, is BEST?
- A. You can trust me. There are no agents here.'
- B. You must feel afraid if you believe that, but there are no agents here.'
- C. No one here will hurt you. They are here to help you.'
- D. Agents? Tell me more about what you mean.'
Correct Answer: B
Rationale: Strategy: Remember therapeutic communication. (1) nontherapeutic, fails to respond to feeling tone, trust builds through interactions (2) correct-patient experiencing delusion (persistent false belief), responds to feeling tone, acknowledges that patient believes it to be true, represents reality (3) statement of reassurance, but denies acceptance of patient's feelings (4) should not encourage patient to explain delusions, would serve to reinforce them