Nursing Elites

1. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most beneficial?

• A. Ask the wife how she would like to participate in the client's care
• B. Provide the wife with information about hospice
• C. Encourage the wife to visit after painful treatments are completed
• D. Refer the wife to a support group for family members of those dying of cancer

Correct answer: A

Rationale: The most beneficial nursing intervention in this situation is to ask the wife how she would like to participate in the client's care. Involving the spouse in the care of the terminally ill client can provide comfort, support, and a sense of contribution during a challenging time. Providing information about hospice (B) is important but may not be the immediate priority. Encouraging the wife to visit after treatments are completed (C) may delay her involvement in the care. Referring her to a support group (D) is a good idea but might be more suitable at a later stage.

2. The father of an 11-year-old client reports to the nurse that the client has been wetting the bed since the passing of his mother and is concerned. Which action is most important for the nurse to take?

• A. Reassure the father that it is normal for a pre-teen to wet the bed during times of stress
• B. Inform the father that nocturnal emissions are abnormal and his son is developmentally delayed
• C. Inform the father that it is most important to let the son know that bedwetting is normal after trauma
• D. Refer the father and the client to a psychologist

Correct answer: D

Rationale: It is common for children to experience bedwetting as a response to severe trauma, such as losing a parent. Referring the father and the client to a psychologist is crucial in this situation to help the child cope with the loss and address any underlying emotional issues. Choice A is incorrect as bedwetting in this context is likely related to the trauma rather than puberty. Choice B is incorrect as nocturnal emissions are not abnormal and do not relate to bedwetting. Choice C is incorrect because the focus should be on addressing the emotional impact of the trauma rather than specifically discussing bedwetting.

3. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe? (Select all that apply).

• A. Tops of the ears
• B. Bridge of the nose
• C. Around the nostrils
• D. Over the cheeks

Correct answer: C

Rationale: The correct answer is C: 'Around the nostrils.' Constant pressure from the tubing may create skin damage to the areas of skin and bony prominences the nasal cannula will be resting on, including around the nostrils. Choice A, 'Tops of the ears,' is incorrect as the cannula does not rest on the ears. Choice B, 'Bridge of the nose,' is incorrect because the cannula typically rests under the nose. Choice D, 'Over the cheeks,' is also incorrect as the cannula does not typically rest on the cheeks.

4. A nurse in the outpatient clinic is caring for a patient who has a magnesium level of 1.3 mg/dL. Which assessment would be most important for the nurse to make?

• A. Daily alcohol intake
• B. Intake of dietary protein
• C. Multivitamin/mineral use
• D. Use of over-the-counter (OTC) laxatives

Correct answer: A

Rationale: The correct answer is A: Daily alcohol intake. Hypomagnesemia is often associated with alcoholism, making it crucial for the nurse to assess the patient's alcohol consumption. Protein intake is not directly related to magnesium levels. The use of over-the-counter laxatives and multivitamin/mineral supplements would typically increase magnesium levels, which are not the focus when dealing with hypomagnesemia.

5. The nurse is teaching the parent of a child newly diagnosed with a latex allergy. Which information by the parents indicates a need for further teaching?

• A. Rubber-free toys, such as wooden building blocks, are good choices for the child.
• B. Only foil balloons will be used for the child's birthday party.
• C. A diet of healthy fruits, such as bananas and kiwis, is best for the child.
• D. An epinephrine auto-injector will be on hand to treat allergic reactions.

Correct answer: C

Rationale: The correct answer is C. Bananas and kiwis are foods that can cross-react with latex allergy, indicating that the parents need further teaching on managing latex allergies. Choices A, B, and D are correct as rubber-free toys, using foil balloons, and having an epinephrine auto-injector are appropriate measures to prevent and manage allergic reactions in a child with a latex allergy.

Similar Questions