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Question 1 of 5

A client with paranoid thoughts refuses to eat because of the belief that the food is poisoned. The appropriate statement at this time for the nurse to say is

Correct Answer: C

Rationale: Reassurance is ineffective when a client is actively delusional. This option avoids both arguing with the client and agreeing with the delusional premise.

Question 2 of 5

A client who is pregnant comes to the clinic for a first visit. The nurse gathers data about her obstetric history, which includes 3 year-old twins at home and a miscarriage 10 years ago. She is 8 weeks pregnant. Which description of her obstetric history is written correctly?

Correct Answer: C

Rationale: Gravida 3 para 1. Gravida is the number of pregnancies and Parity is the number of pregnancies that reach viability (not the number of fetuses). Thus, for this woman, she is now pregnant, had 2 prior pregnancies, and 1 viable birth (twins).

Question 3 of 5

A Spanish-speaking client is admitted for a small bowel obstruction. The surgeon explains to the client's child, who speaks both Spanish and English, that an exploratory laparotomy is needed to determine the cause of the obstruction and that possible causes include intestinal adhesions and ovarian or colon cancer. The surgeon asks the child to translate this information for the client and assist with translating the consent form. Which action by the nurse would be most appropriate?

Correct Answer: D

Rationale: Using a trained interpreter ensures accurate, unbiased communication. Witnessing or reinforcing perpetuates the error, and reporting is premature.

Question 4 of 5

The nurse reinforces teaching about the use of the peak flow meter to evaluate airflow to a client newly diagnosed with asthma. Which statement by the client indicates an understanding of the nurse's teaching?

Correct Answer: A

Rationale: Exhaling quickly is the correct technique for peak flow. Setting the indicator , recording the lowest reading , and using post-inhaler are incorrect.

Question 5 of 5

A client is receiving Vincristine (Marqibo). The client should be taught that the medication can:

Correct Answer: C

Rationale: Vincristine can cause neurotoxicity, including mental confusion. Diarrhea, urine color changes, and taste alterations are less common.

Similar Questions

The nurse is participating in staff training about protecting clients' privacy and confidentiality. Which of the following incidents does the nurse recognize as a violation of client confidentiality? Select all that apply.
The nurse is preparing to administer a scheduled dose of metoclopramide IV to a client with diabetic gastroparesis. Which clinical finding causes the nurse to question the prescription?
The nurse is caring for a client with a seizure disorder. Which of the following seizure precautions should the nurse implement? Select all that apply.
The nurse is inserting an indwelling urinary catheter for a female client. After inserting and advancing the catheter, the nurse notes no return of urine. Which of the following actions should the nurse take?
An adult is almost ready for discharge. She has a complicated care regimen to follow. When conducting client teaching, the nurse notes that the client cannot recall basic information that was discussed the day before. The client also appears distracted. When asked if she is feeling comfortable about leaving the hospital, she states, 'There's just too much to learn. I know I'm going to get home and mess something up.' The nurse realizes that the client may be experiencing:

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