Nokea
While talking to her husband, who is caring for their children, a 52-year-old client slams the phone down. She begins to cry and states that she is feeling guilty for being hospitalized. Which of the following interventions will best support the client emotionally?
- A. Call the physician and ask for a psychiatry consultation.
- B. Call the physician and request an antidepressant medication.
- C. Sit with the client and help her acknowledge and discuss her feelings.
- D. Sit with the client and encourage her to see the good side of the situation.
Correct Answer: C
Rationale: Sitting with the client and helping her discuss her feelings validates her emotions and supports her in processing guilt, providing emotional relief.
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A client has acute arterial occlusion. The physician has ordered a thrombolytic agent. Before starting the medication, the nurse should:
- A. Review the blood coagulation laboratory values
- B. Test the client's stools for occult blood
- C. Count the client's apical pulse for 1 minute
- D. Check the 24-hour urine output record
Correct Answer: A
Rationale: Before administering a thrombolytic agent for acute arterial occlusion, the nurse must review coagulation lab values (e.g., aPTT, INR, platelets) to assess bleeding risk, as thrombolytics increase hemorrhage potential. Stool testing, pulse counting, and urine output are secondary or unrelated.
The nurse is developing a plan of care for the client with viral hepatitis. The nurse should instruct the client to:
- A. Obtain adequate bed rest.
- B. Increase fluid intake.
- C. Follow a high-protein diet.
- D. Avoid carbohydrates.
Correct Answer: A
Rationale: Adequate bed rest (A) reduces metabolic demands and supports recovery in viral hepatitis. Increased fluids (B) are supportive but secondary. High-protein diets (C) or avoiding carbohydrates (D) are not indicated for hepatitis management.
Assessment of the diabetic client for common complications should include examination of the:
- A. Abdomen.
- B. Lymph glands.
- C. Pharynx.
- D. Eyes.
Correct Answer: D
Rationale: Diabetic retinopathy, a common complication, requires regular eye examinations to detect and prevent vision loss.
A client with breast cancer has abdominal bloating and cramping with no bowel movement for 5 days. She says she usually has a bowel movement every day after her morning coffee. Bowel sounds are present in all four quadrants. She received 80 mg of doxorubicin hydrochloride (Adriamycin) 10 days ago. The nurse should contact the health care provider to request an order for which of the following?
- A. A Fleet enema to stimulate peristalsis.
- B. A soapsuds enema until clear.
- C. A small-volume tap water enema to stimulate a bowel movement; then evaluate the need for daily stool softeners.
- D. A daily stool softener for constipation and a mild opioid for abdominal discomfort.
Correct Answer: C
Rationale: A small-volume tap water enema is a gentle, effective intervention to stimulate a bowel movement, followed by evaluation for stool softeners to prevent recurrence, addressing chemotherapy-related constipation.
The nurse is caring for a client who is receiving prescribed aspirin. Which of the following findings would indicate the client is having an adverse effect?
- A. Polyuria
- B. Hypokalemia
- C. Venous thromboembolism
- D. Black, tarry stools
Correct Answer: D
Rationale: Black, tarry stools indicate gastrointestinal bleeding, a serious adverse effect of aspirin due to its antiplatelet and irritant properties.