Nokea
You are planning discharge education for your client who has a new colostomy. Which complication of a colostomy should you educate this client about?
- A. A prolapsed stoma
- B. A vitamin B12 deficiency
- C. Nocturnal enuresis
- D. GI stone formation
Correct Answer: A
Rationale: A prolapsed stoma is a known complication of a colostomy, where the stoma protrudes excessively, and clients should be educated to recognize and report it.
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The nurse is caring for a client with a history of atrial fibrillation who is prescribed amiodarone (Cordarone). Which of the following side effects should the nurse monitor for?
- A. Pulmonary toxicity.
- B. Hyperglycemia.
- C. Weight gain.
- D. Hair loss.
Correct Answer: A
Rationale: Amiodarone can cause pulmonary toxicity, a serious side effect requiring regular monitoring of lung function.
A nurse is assessing an 82-year-old for depression, because of the client's age, the nurses' assessment should be guided by the fact that:
- A. Sadness of mood is usually present but it is masked by other symptoms.
- B. Impairment of cognition usually is not present.
- C. Psychosomatic tendencies do not tend to dominate.
- D. Antidepressant therapies are less effective in older adults.
Correct Answer: A
Rationale: In older adults, depression may present with atypical symptoms, such as somatic complaints or irritability, rather than overt sadness, which can mask the condition.
A client with severe major depression states, 'My heart has stopped and my blood is black ash.' The nurse interprets this statement to be evidence of which of the following?
- A. Hallucination.
- B. Illusion.
- C. Delusion.
- D. Paranoia.
Correct Answer: C
Rationale: The client's statement reflects a false, fixed belief that is not based in reality, which is characteristic of a delusion. Hallucinations involve sensory perceptions, illusions are misinterpretations of stimuli, and paranoia involves suspicion, none of which fit this scenario.
When the nurse is assessing a client's cultural adaptation, which of the following statements is least sensitive to the client's needs?
- A. What are some of your favorite foods?'
- B. Describe any health problems in your past.'
- C. Please tell me how you would like to be addressed.'
- D. Your eyes look dark; is this normal for you?'
Correct Answer: D
Rationale: Commenting on the client's appearance (dark eyes) is insensitive and irrelevant to cultural adaptation, potentially making the client uncomfortable.
A client being mechanically ventilated after experiencing a fat embolus is visibly anxious. Which action should the nurse take?
- A. Remain with the client and provide reassurance.
- B. Ask a family member to stay with the client at all times.
- C. Encourage the client to sleep until arterial blood gas results improve.
- D. Ask the primary health care provider to write a prescription for an antianxiety medication.
Correct Answer: A
Rationale: The nurse always speaks to the client calmly and provides reassurance to the anxious client. Family members are also stressed because of the severity of the situation; therefore, it is not beneficial to ask the family to take on the burden of remaining with the client at all times. Encouraging the client to sleep will not assist in relieving the client's anxiety. Antianxiety medications are used only if necessary and if other interventions fail to relieve the client's anxiety.