Cover the key. Write the first action. Then open the rationale and name why the other choices fail.
Question 1
A patient taking medication for depression states, “I need to stop taking my medication because it blurs my vision, and I’m making mistakes when I paint jewelry by hand.†Which response by a nurse would be most therapeutic?
- A. “If you cannot take medication, would you consider a course of 6 to 10 electroconvulsive therapy (ECT) treatments offered on an outpatient basis? ECT treatments usually work immediately.â€
- B. “Do you recall the two of us discussing that blurred vision may occur but that it will resolve shortly? In the meantime, you might find a magnifying glass helpful.â€
- C. “I understand your concern considering that you need to work to receive health insurance. Would you like me to ask the psychiatrist to change your medication?â€
- D. “You may need to apply for a sick leave for 6 months until your depression improves enough to lessen the medication dosage.â€
Show answer and rationale
Correct answer: B — “Do you recall the two of us discussing that blurred vision may occur but that it will resolve shortly? In the meantime, you might find a magnifying glass helpful.â€
Answer B is the most therapeutic response because it acknowledges the patient's concern about blurred vision and offers a practical solution to address it. By reminding the patient that blurred vision is a known side effect that will resolve shortly and suggesting the use of a magnifying glass as a temporary aid, the nurse validates the patient's experience and provides support. This response promotes open communication, reassures the patient, and empowers them to manage the side effect effectively.
The other choices are incorrect because:
A: Recommending ECT treatments without exploring alternative solutions or addressing the patient's concerns about medication side effects is not therapeutic.
C: Suggesting a medication change without first addressing the current side effect and exploring other options does not address the patient's immediate issue.
D: Recommending a sick leave as the first solution without exploring less disruptive options or addressing the patient's concerns is not therapeutic.
Question 2
The physician orders penicillin for a female client who has a sinus infection. What is a priority question to ask the client prior to administering the medication?
- A. Are you pregnant?'
- B. Do you plan to become pregnant?'
- C. Are you breastfeeding?'
- D. Are you taking birth control pills?'
Show answer and rationale
Correct answer: A — Are you pregnant?'
Penicillin is a commonly used antibiotic for infections like sinusitis, but its safety profile must be assessed, especially in female clients of reproductive age. The priority question is whether the client is pregnant because penicillin is classified as a Category B drug by the FDA, meaning it's generally considered safe during pregnancy, but confirmation of pregnancy status is critical to ensure no unforeseen risks or contraindications exist, such as hypersensitivity. Pregnancy also affects drug metabolism and dosing considerations, making this the most immediate concern. Asking about plans to become pregnant is less urgent, as it pertains to future rather than current status. Breastfeeding is important due to potential drug excretion in milk, but it's secondary to confirming current pregnancy. Birth control pills might interact with some antibiotics (though less so with penicillin), but this is not the primary safety concern. Thus, choice A is the priority question to ensure safe administration.
Question 3
A patient taking medication for depression states, “I need to stop taking my medication because it blurs my vision, and I’m making mistakes when I paint jewelry by hand.” Which response by a nurse would be most therapeutic?
- A. “If you cannot take medication, would you consider a course of 6 to 10 electroconvulsive therapy (ECT) treatments offered on an outpatient basis? ECT treatments usually work immediately.”
- B. “Do you recall the two of us discussing that blurred vision may occur but that it will resolve shortly? In the meantime, you might find a magnifying glass helpful.”
- C. “I understand your concern considering that you need to work to receive health insurance. Would you like me to ask the psychiatrist to change your medication?”
- D. “You may need to apply for a sick leave for 6 months until your depression improves enough to lessen the medication dosage.”
Show answer and rationale
Correct answer: B — “Do you recall the two of us discussing that blurred vision may occur but that it will resolve shortly? In the meantime, you might find a magnifying glass helpful.”
Answer B is the most therapeutic response because it acknowledges the patient's concern about blurred vision and offers a practical solution to address it. By reminding the patient that blurred vision is a known side effect that will resolve shortly and suggesting the use of a magnifying glass as a temporary aid, the nurse validates the patient's experience and provides support. This response promotes open communication, reassures the patient, and empowers them to manage the side effect effectively.
The other choices are incorrect because:
A: Recommending ECT treatments without exploring alternative solutions or addressing the patient's concerns about medication side effects is not therapeutic.
C: Suggesting a medication change without first addressing the current side effect and exploring other options does not address the patient's immediate issue.
D: Recommending a sick leave as the first solution without exploring less disruptive options or addressing the patient's concerns is not therapeutic.
Question 4
The nurse is caring for a client who has just had a modified radical mastectomy with immediate reconstruction. She’s in her 30s and has two young children. Although she’s worried about her future, she seems to be adjusting well to her diagnosis. What should the nurse do to support her coping?
- A. Tell the client’s spouse or partner to be supportive while she recovers.
- B. Encourage the client to proceed with the next phase of treatment.
- C. Recommend that the client remain cheerful for the sake of her children.
- D. Refer the client to the American Cancer Society’s Reach for Recovery program or another support program.
Show answer and rationale
Correct answer: D — Refer the client to the American Cancer Society’s Reach for Recovery program or another support program.
The correct answer is D: Refer the client to the American Cancer Society’s Reach for Recovery program or another support program. This choice is the best option as it provides the client with additional support and resources specifically tailored to individuals coping with cancer and mastectomy. The Reach for Recovery program offers emotional support, education, and practical assistance which can immensely benefit the client during this challenging time.
A: Involving the client's spouse or partner is important, but support programs like Reach for Recovery can offer specialized assistance that may not be fully covered by the spouse's support alone.
B: While proceeding with the next phase of treatment is important, emotional support and coping mechanisms are equally crucial, which support programs can provide.
C: Asking the client to remain cheerful may put pressure on her and may not address her emotional needs adequately, unlike a support program that is designed to provide comprehensive support.
Question 5
When administering a blood transfusion to a client with multiple traumatic injuries, the nurse monitors closely for evidence of a transfusion reaction. Shortly after the transfusion begins, the client complains of chest pain, nausea and itching. When urticarial, tachycardia, and hypotension develop, the nurse stops the transfusion and notifies the physician. The nurse suspects which type of hypersensitivity reaction?
- A. Type I (immediate, anaphylactic) hypersensitivity reaction
- B. Type II (cytolytic, cytotoxic) hypersensitivity reaction
- C. Type III (immune complex) hypersensitivity reaction
- D. Type IV (cell-mediated, delayed) hypersensitivity reaction
Show answer and rationale
Correct answer: A — Type I (immediate, anaphylactic) hypersensitivity reaction
The correct answer is A: Type I (immediate, anaphylactic) hypersensitivity reaction. In this scenario, the client experiences symptoms shortly after the transfusion starts, such as chest pain, nausea, itching, urticaria, tachycardia, and hypotension, which are indicative of an immediate hypersensitivity reaction. Type I reactions involve the release of histamine and other inflammatory mediators from mast cells and basophils, leading to the symptoms described. The nurse's prompt action of stopping the transfusion and notifying the physician aligns with managing this type of reaction.
Incorrect choices:
B: Type II (cytolytic, cytotoxic) hypersensitivity reaction - This type of reaction involves antibodies targeting specific cells, leading to their destruction. The symptoms described in the scenario are not consistent with this type of reaction.
C: Type III (immune complex) hypersensitivity reaction - This type of reaction involves the formation of immune complexes that deposit in tissues, causing
