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Which of these clients, all of whom have the findings of a board-like abdomen, would the nurse suggest that the provider examine first?
- A. An elderly client who stated, 'My awful pain in my right side suddenly stopped about 3 hours ago.'
- B. A pregnant woman of 8 weeks newly diagnosed with an ectopic pregnancy
- C. A middle-aged client admitted with diverticulitis who has taken only clear liquids for the past week
- D. A teenager with a history of falling off a bicycle without hitting the handle bars
Correct Answer: A
Rationale: An elderly client who stated, 'My awful pain in my right side suddenly stopped about 3 hours ago.' This client has the highest risk for hypovolemic and septic shock since the appendix has most likely ruptured, based on the history of the pain suddenly stopping over three hours ago. Elderly clients have less functional reserve for the body to cope with shock and infection over long periods. The others are at risk for shock also, however given that they fall in younger age groups, they would more likely be able to tolerate an imbalance in circulation. A common complication of falling off a bicycle is hitting the handle bars in the upper abdomen often on the left, resulting in a ruptured spleen.
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The nurse is preparing to take a toddler's blood pressure for the first time. Which of the following actions should the nurse perform first?
- A. Explain that the procedure will help him to get well
- B. Show a cartoon character with a blood pressure cuff
- C. Explain that the blood pressure checks the heart pump
- D. Permit handling the equipment before putting the cuff in place
Correct Answer: D
Rationale: Permit handling the equipment before putting the cuff in place. The best way to gain the toddler's cooperation is to encourage handling the equipment. Detailed explanations are not helpful.
The nurse is collecting data from a client with suspected panic disorder. Which of the following findings would be consistent with the condition?
- A. sweating
- B. dizziness
- C. compulsions
- D. heart palpitations
- E. shortness of breath
Correct Answer: A,B,D,E
Rationale: Panic disorder is characterized by sudden, intense fear accompanied by physical symptoms such as sweating (A), dizziness (B), heart palpitations (D), and shortness of breath (E). Compulsions (C) are associated with obsessive-compulsive disorder, not panic disorder.
The nurse is caring for a client with benign prostatic hypertrophy (BPH). Which of the following assessments would the nurse anticipate finding?
- A. Large volume of urinary output with each voiding
- B. Involuntary voiding with coughing and sneezing
- C. Frequent urination
- D. Urine is dark and concentrated
Correct Answer: C
Rationale: Frequent urination. BPH causes overflow incontinence with frequent urination in small amounts due to bladder obstruction.
The nurse has delegated the task of taking the temperature of a client with a new tympanic thermometer to a certified nursing assistant. The nursing assistant says, 'This looks easy. I am good at figuring things out.' What is the nurse's responsibility?
- A. Allow the nursing assistant to proceed.
- B. Assign the task to another nursing assistant.
- C. Ask another nursing assistant to demonstrate this task to the nursing assistant.
- D. Demonstrate the proper use of the thermometer and observe the nursing assistant.
Correct Answer: D
Rationale: Demonstrating and observing ensures the CNA uses the tympanic thermometer correctly, maintaining accuracy and safety.
The parents of a 4-year-old tell the nurse that the child won't go to sleep at night due to fear of tigers living under the bed. Which response by the nurse is most helpful?
- A. Have you recently visited the zoo? Maybe the tigers looked scary.
- B. If you agree with your child, the fears could continue through this developmental stage.
- C. Night fears are common at this age. Look under the bed with your child.
- D. This is very unusual. Maybe the child saw something scary on TV.
Correct Answer: C
Rationale: Night fears are normal in preschoolers (C). Checking under the bed with the child validates their fear while showing safety. Linking to a zoo visit (A) or media (D) assumes unconfirmed triggers. Agreeing with fears (B) may reinforce them.