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1. The nurse is managing the care of a client with Cushing's syndrome. Which interventions should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply)
- A. Evaluate the client for sleep disturbances
- B. limit client exercise
- C. Report any client complaint of pain or discomfort
- D. Note and report the client's food and liquid intake during meals and snacks
Correct answer: D
Rationale: Weighing the client and monitoring food and liquid intake are appropriate tasks to delegate to the unlicensed assistive personnel (UAP) when managing a client with Cushing's syndrome. These tasks provide essential information for evaluating the client's condition and response to treatment. Evaluating for sleep disturbances and reporting client complaints of pain or discomfort require a higher level of assessment and interpretation, which should be performed by licensed healthcare providers. Therefore, options A and C are tasks that involve assessment and interpretation beyond the scope of practice for UAP.
2. The nurse is assigned to care for a client diagnosed with psoriasis. What behavior by the nurse addresses this client's psychosocial need for acceptance?
- A. Wearing gloves when providing care to the client
- B. Encouraging the client to join a support group
- C. Shaking hands with the client during an introduction
- D. Allowing the client to express their feelings openly
Correct answer: B
Rationale: Encouraging the client to join a support group is the best option to address the client's psychosocial need for acceptance. Support groups provide a sense of belonging, understanding, and acceptance from peers who share similar experiences. This helps the client feel accepted despite their condition. Wearing gloves when providing care, shaking hands during an introduction, and allowing the client to express feelings openly are important but do not directly address the client's need for acceptance.
3. An infant is receiving penicillin G procaine 220,000 units IM. The drug is supplied as 600,000 units/ml. How many ml should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth)
- A. 0.4
- B.
- C.
- D.
Correct answer: A
Rationale: To calculate the volume to administer, use the formula: Desired dose (220,000 units) / Dose on hand (600,000 units) x Volume of the available dose (1 ml). This results in 0.4 ml to be administered. Choice A is correct. Choice B, C, and D are incorrect as they are not provided.
4. The mother of a teenager is told that her son has recently been found stealing from other students at school. The mother's response is, 'I cannot think about that today.' The nurse determines that this mother is using which defense mechanism?
- A. Suppression
- B. Repression
- C. Sublimation
- D. Undoing
Correct answer: A
Rationale: The correct answer is A, Suppression. Suppression involves a conscious effort to avoid dealing with distressing thoughts or feelings. In this case, the mother is consciously choosing not to think about her son's behavior. Choice B, Repression, involves unconsciously blocking out distressing thoughts or feelings. Choice C, Sublimation, is the channeling of unacceptable impulses into socially acceptable behaviors, which is not demonstrated in this scenario. Choice D, Undoing, is a defense mechanism where a person tries to undo or reverse a negative thought or action by performing a contrary behavior, which is not applicable here.
5. A client with osteoporosis related to long-term corticosteroid therapy receives a prescription for calcium carbonate. Which client’s serum laboratory value requires intervention by the nurse?
- A. Total calcium 9 mg/dl (2.25 mmol/L SI)
- B. Creatinine 4 mg/dl (354 micromol/L SI)
- C. Phosphate 4 mg/dl (1.293 mmol/L SI)
- D. Fasting glucose 95 mg/dl (5.3 mmol/L SI)
Correct answer: B
Rationale: An elevated creatinine level indicates possible renal impairment, which requires intervention. High creatinine levels are associated with decreased kidney function, and in this case, it suggests potential renal issues due to long-term corticosteroid therapy. Monitoring renal function is crucial in clients with osteoporosis on corticosteroid therapy to prevent further complications. Total calcium levels within the normal range are suitable for a client with osteoporosis receiving calcium carbonate. Phosphate and fasting glucose levels do not directly indicate renal impairment in this scenario.
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