Nokea
While sitting in the cafeteria, a nurse overhears two students discussing a client admitted for chemical detoxification. The nurse should:
- A. Report the incident to the teacher.
- B. Report the incident to the nursing supervisor.
- C. Confront the students with their behavior.
- D. Ignore the students' behavior.
Correct Answer: C
Rationale: Confronting the students addresses the breach of confidentiality directly and educates them. Reporting to the teacher or supervisor escalates unnecessarily, and ignoring the behavior allows the violation to persist.
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At a well baby clinic the nurse is assigned to assess an 8 month-old child. Which of these developmental achievements would the nurse anticipate that the child would be able to perform?
- A. Say 2 words
- B. Pull up to stand
- C. Sit without support
- D. Drink from a cup
Correct Answer: C
Rationale: Sit without support. This is a typical developmental milestone for an 8-month-old.
A client who has a known history of cardiac problems and is still smoking enters the clinic complaining of sudden onset of sharp, stabbing pain that intensifies with a deep breath. The pain is occurring on only one side and can be isolated upon general assessment. The nurse concludes that this description is most likely caused by:
- A. pleurisy.
- B. pleural effusion.
- C. atelectasis.
- D. tuberculosis.
Correct Answer: A
Rationale: Pleurisy is an inflammation of the pleura and is often accompanied by abrupt onset of pain. Symptoms of pleurisy are abrupt pain that is usually unilateral and localized to a specific portion of the chest.
A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present
- A. Temperature of 99.5 degrees Fahrenheit with painful urination
- B. An open, reddened wound on the heel
- C. Insomnia and daytime fatigue
- D. Nausea with 2 episodes of vomiting
Correct Answer: B
Rationale: An open, reddened wound on the heel. When signs of trauma and/or infection occur in their feet, elderly clients who have diabetes and/or vascular disease should seek health care quickly and continue treatment until the problem is resolved. Without treatment, serious infection, gangrene, limb loss, and death may result.
Diltiazem (Cardizem) 90 mg qid is prescribed for an adult who has angina. Which statement by the client indicates a need for further instruction?
- A. I will take the pills before meals and at bedtime.
- B. I will call my physician if the pain gets worse than it has been.
- C. If my heart rate is less than 70, I will not take the pill.
- D. I will get up slowly when I stand up.
Correct Answer: C
Rationale: Diltiazem is not typically withheld based on heart rate alone unless specified; this indicates a need for clarification on administration instructions.
The parent of a 7-month-old reports that the child has been crying and vomiting with a distended belly for the past 4 hours. The infant is now lying quietly in the parent's arms with a pulse of 200/min and respirations of 60/min. Which of the following components of SBAR (situation, background, assessment, recommendation/read back) communication is most important for the nurse to report?
- A. Client has been ill for approximately 4 hours
- B. Client has improved from apparent earlier distress
- C. Client is now lethargic with abnormal vital signs
- D. Does the health care provider want to order a laxative?
Correct Answer: C
Rationale: The infant's lethargy with tachycardia (200/min) and tachypnea (60/min) are critical, suggesting a serious condition like intussusception or volvulus, requiring urgent reporting. Duration , perceived improvement , and laxative suggestion are less critical.