AND CORRECT ANSWERS (VERIFIED ANSWERS)
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The nurse observes an unlicensed assistive personnel (UAP)
positioning a newly admitted client who has a seizure disorder.
The client is supine and the UAP is placing soft pillows along the
side rails. What action should the nurse implement?
a. Ensure that the UAP has placed the pillows effectively to
protect the client.
b. Instruct the UAP to obtain soft blankets to secure to the side
rails instead of pillows.
c. Assume responsibility for placing the pillows while the UAP
completes another task.
d. Ask the UAP to use some of the pillows to prop the client in a
side lying position.
Instruct the UAP to obtain soft blankets to secure to the side
rails instead of pillows
,Rationale: The nurse should instruct the UAP to pad the side
rails with soft blankest because the use of pillows could result in
suffocation and would need to be removed at the onset of the
seizure. The nurse can delegate paddling the side rails to the
UAP
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An adolescent with major depressive disorder has been taking
duloxetine (Cymbalta) for the past 12 days. Which assessment
finding requires immediate follow-up
a. Describes life without purpose
b. Complains of nausea and loss of appetite
c. States is often fatigued and drowsy
d. Exhibits an increase in sweating.
Describes life without purpose
Rationale: Cymbalta is a selective serotonin and norepinephrine
reuptake inhibitor that is known to increase the risk of suicidal
thinking in adolescents and young adults with major depressive
disorder. B, C and D are side effects
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A 60-year-old female client with a positive family history of
ovarian cancer has developed an abdominal mass and is being
evaluated for possible ovarian cancer. Her Papanicolau (Pap)
smear results are negative. What information should the nurse
include in the client's teaching plan
a. Further evaluation involving surgery may be needed
b. A pelvic exam is also needed before cancer is ruled out
c. Pap smear evaluation should be continued every six month
d. One additional negative pap smear in six months is needed.
Further evaluation involving surgery may be needed
Rationale: An abdominal mass in a client with a family history
for ovarian cancer should be evaluated carefully
Following discharge teaching, a male client with duodenal ulcer
tells the nurse the he will drink plenty of dairy products, such as
milk, to help coat and protect his ulcer. What is the best follow-
up action by the nurse?
, a. Remind the client that it is also important to switch to
decaffeinated coffee and tea.
b. Suggest that the client also plan to eat frequent small meals
to reduce discomfort
c. Review with the client the need to avoid foods that are rich in
milk and cream.
d. Reinforce this teaching by asking the client to list a dairy food
that he might select.
Review with the client the need to avoid foods that are rich in
milk and cream
Rationale: Diets rich in milk and cream stimulate gastric acid
secretion and should be avoided.
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A male client with hypertension, who received new
antihypertensive prescriptions at his last visit returns to the
clinic two weeks later to evaluate his blood pressure (BP). His
BP is 158/106 and he admits that he has not been taking the
prescribed medication because the drugs make him "feel bad".
In explaining the need for hypertension control, the nurse
should stress that an elevated BP places the client at risk for
which pathophysiological condition?