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Questions 176

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Question 1 of 5

The nurse is caring for a client with polycythemia vera. Which of the following actions should the nurse take? Select all that apply.

Correct Answer: A, B, C

Rationale: Increased fluids (
A), phlebotomy (
B), and aspirin (
C) manage polycythemia vera by reducing blood viscosity and clotting risk. Leg elevation (
D) is irrelevant, and iron supplementation (E) worsens the condition.

Question 2 of 5

A client continually repeats phrases that others have just said. The nurse recognizes this behavior as

Correct Answer: C

Rationale: Echolalia is repeating words or phrases heard before, often seen in certain psychiatric or developmental conditions.

Question 3 of 5

In assessing the healing of a client's wound during a home visit, which of the following is the best indicator of good healing?

Correct Answer: C

Rationale: Reddened tissue. Redness indicates granulation tissue formation, a sign of healing.

Question 4 of 5

A community health nurse is preparing to administer influenza vaccines. Which clients can safely receive the live-attenuated, intranasal influenza vaccine? Select all that apply.

Correct Answer: B, C

Rationale: The live-attenuated vaccine is safe for healthy individuals aged 2-49, like the 3-year-old (
B) and postpartum client (
C). It's contraindicated for infants under 2 (
A), pregnant women (
D), and immunocompromised clients (E).

Question 5 of 5

Which therapeutic communication skill used by the nurse is most likely to encourage a depressed client to vent feelings?

Correct Answer: D

Rationale: Active listening. This skill, along with silence, encourages the client to verbalize feelings.

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