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Three days following surgery, a male client observes his colostomy for the
first time. He becomes quite upset and tells the nurse that it is much bigger
than he expected. What is the best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma
appearance in time.
B. Instruct the client that the stoma will become smaller when the initial
swelling diminishes.
C. Offer to contact a member of the local ostomy support group to help him
with his concerns.
D. Encourage the client to handle the stoma equipment to gain confidence
with the procedure. ---------CORRECT ANSWER-----------------
Postoperative swelling causes enlargement of the stoma. The nurse
can teach the client that the stoma will become smaller when the
swelling is diminished (B). This will help reduce the client's anxiety
and promote acceptance of the colostomy. (A) does not provide
helpful teaching or support. (C) is a useful action, and may be taken
after the nurse provides pertinent teaching. The client is not yet
demonstrating readiness to learn colostomy care (D).
Correct Answer: B
At the time of the first dressing change, the client refuses to look at her
mastectomy incision. The nurse tells the client that the incision is healing
well, but the client refuses to talk about it. What would be an appropriate
response to this client's silence?
A. "It is normal to feel angry and depressed, but the sooner you deal with
this surgery, the better you will feel."
,B. "Looking at your incision can be frightening, but facing this fear is a
necessary part of your recovery."
C. "It is OK if you don't want to talk about your surgery. I will be available
when you are ready."
D. "I will ask a woman who has had a mastectomy to come by and share
her experiences with you." ---------CORRECT ANSWER-----------------(C)
displays sensitivity and understanding without judging the client. (A)
is judgmental in that it is telling the client how she feels and is also
insensitive. (B) would give the client a chance to talk, but is also
demanding and demeaning. (D) displays a positive action, but,
because the nurse's personal support is not offered, this response
could be interpreted as dismissing the client and avoiding the
problem.
Correct Answer: C
The nurse witnesses the signature of a client who has signed an informed
consent. Which statement best explains this nursing responsibility?
A. The client voluntarily signed the form.
B. The client fully understands the procedure.
C. The client agrees with the procedure to be done.
D. The client authorizes continued treatment. ---------CORRECT ANSWER-
----------------The nurse signs the consent form to witness that the client
voluntarily signs the consent (A), that the client's signature is
authentic, and that the client is otherwise competent to give consent.
It is the healthcare provider's responsibility to ensure the client fully
understands the procedure (B). The nurse's signature does not
indicate (C or D).
Correct Answer: A
The nurse assigns a UAP to obtain vital signs from a very anxious client.
What instructions should the nurse give the UAP?
A. Remain calm with the client and record abnormal results in the chart.
,B. Notify the medication nurse immediately if the pulse or blood pressure is
low.
C. Report the results of the vital signs to the nurse.
D. Reassure the client that the vital signs are normal. ---------CORRECT
ANSWER-----------------Interpretation of vital signs is the responsibility
of the nurse, so the UAP should report vital sign measurements to the
nurse (C). (A, B, and D) require the UAP to interpret the vital signs,
which is beyond the scope of the UAP's authority.
Correct Answer: C
An adult male client with a history of hypertension tells the nurse that he is
tired of taking antihypertensive medications and is going to try spiritual
meditation instead. What should be the nurse's first response?
A. "It is important that you continue your medication while learning to
meditate."
B. "Spiritual meditation requires a time commitment of 15 to 20 minutes
daily."
C. "Obtain your healthcare provider's permission before starting
meditation."
D. "Complementary therapy and western medicine can be effective for
you." ---------CORRECT ANSWER-----------------The prolonged practice of
meditation may lead to a reduced need for antihypertensive
medications. However, the medications must be continued (A) while
the physiologic response to meditation is monitored. (B) is not as
important as continuing the medication. The healthcare provider
should be informed, but permission is not required to meditate (C).
Although it is true that this complimentary therapy might be effective
(D), it is essential that the client continue with antihypertensive
medications until the effect of meditation can be measured.
Correct Answer: A
, Examination of a client complaining of itching on his right arm reveals a
rash made up of multiple flat areas of redness ranging from pinpoint to 0.5
cm in diameter. How should the nurse record this finding?
A. Multiple vesicular areas surrounded by redness, ranging in size from 1
mm to 0.5 cm.
B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in
diameter.
C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size.
D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in
diameter. ---------CORRECT ANSWER-----------------Macules are localized
flat skin discolorations less than 1 cm in diameter. However, when
recording such a finding the nurse should describe the appearance
(B) rather than simply naming the condition. (A) identifies vesicles --
fluid filled blisters -- an incorrect description given the symptoms
listed. (C) identifies papules -- solid elevated lesions, again not
correctly identifying the symptoms. (D) identifies petechiae -- pinpoint
red to purple skin discolorations that do not itch, again an incorrect
identification.
Correct Answer: B
The nurse is completing a mental assessment for a client who is
demonstrating slow thought processes, personality changes, and emotional
lability. Which area of the brain controls these neuro-cognitive functions?
A. Thalamus.
B. Hypothalamus.
C. Frontal lobe.
D. Parietal lobe. ---------CORRECT ANSWER-----------------The frontal lobe
(C) of the cerebrum controls higher mental activities, such as
memory, intellect, language, emotions, and personality. (A) is an
afferent relay center in the brain that directs impulses to the cerebral
cortex. (B) regulates body temperature, appetite, maintains a wakeful
state, and links higher centers with the autonomic nervous and
endocrine systems, such as the pituitary. (D) is the location of
sensory and motor functions.