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NEW QUESTION 288
Three weeks following discharge, a male client is readmitted to the psychiatric unit for depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse admits him to the unit, he says, "I wish I were dead because I am worthless to everyone; I guess I am just no good." Which response by the nurse is most appropriate at this time?
- A. "I know with your wife and new baby that you do have a lot to live for."
- B. "You've been feeling sad and alone for some time now?"
- C. "Don't you think this is a sign of your illness?"
- D. "I don't think you are worthless. I'm glad to see you, and we will help you."
Answer: B
Explanation:
(A)
This response does not acknowledge the client's feelings.
(B)
This is a closed question and does not encourage communication.
(C)
This response negates the client's feelings and does not require a response from the client. (D) This acknowledges the client's implied thoughts and feelings and encourages a response.
NEW QUESTION 289
A school-age child with asthma is ready for discharge from the hospital. His physician has written an order to continue the theophylline given in the hospital as an oral home medication. Immediately prior to discharge, he complains of nausea and becomes irritable. His vital signs were normal except for tachycardia. What first nursing actions would be essential in this situation?
- A. Hold the child's discharge for 1 hour.
- B. Discharge the child as the physician ordered.
- C. Administer an antiemetic as necessary.
- D. Notify the physician immediately.
Answer: D
Explanation:
(A) Holding the child's discharge alone does not address the client's problem. (B) Nausea, tachycardia, and irritability are all symptoms of theophylline toxicity. The physician should benotified immediately so that a serum theophylline level can be ordered. Theophylline dose should be withheld until the physician is notified. (C) The child must be evaluated for theophylline toxicity before any discharge. (D) Cause of the nausea should be investigated before the administration of an antiemetic.
NEW QUESTION 290
A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?
- A. "When I get home, I should be able to taper myself off the Haldol because the voices are gone now."
- B. "If I have any side effects from my medicines, I will take an extra dose of Cogentin."
- C. "When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices."
- D. "As soon as I leave here, I'm throwing away my medicines. I never thought I needed them anyway."
Answer: C
Explanation:
Explanation
(A) The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts him at the lowest risk for relapse. (B) Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own health maintenance. (C) This statement reflects lack of insight into the importance of compliance. (D) This statement reflects no insight into his illness or his responsibility in health maintenance.
NEW QUESTION 291
Which behavior by a female client feeding her newborn demonstrates that she needs more teaching related to safety and infant feeding?
- A. She places her infant on her right side after feeding her.
- B. She uses the bulb syringe to help clear her baby's nose when milk is regurgitated.
- C. She burps her baby by placing her in a sitting position, supporting her head and neck and gently massaging her back.
- D. She props the bottle in the crib to feed her baby,which allows her to write birth announcements and feed her baby at the same time.
Answer: D
Explanation:
Explanation
(A) This practice is the proper use of the bulb syringe to clear the infant's airway in case of regurgitation. (B) Placing the infant on either side or on the stomach prevents aspiration of regurgitated milk. (C) "Bottle propping" is an unsafe practice because it increases the likelihood of aspiration. (D) This practice is one correct way of burping an infant.
NEW QUESTION 292
Nursing care for the substance abuse client experiencing alcohol withdrawal delirium includes:
- A. Applying ankle and wrist restraints
- B. Maintaining seizure precautions
- C. Restricting fluid intake
- D. Increasing sensory stimuli
Answer: B
Explanation:
(A) These clients are at high risk for seizures during the 1st week after cessation of alcohol intake. (B) Fluid intake should be increased to prevent dehydration. (C) Environmental stimuli should be decreased to prevent precipitation of seizures. (D) Application of restraints may cause the client to increase his or her physical activity and may eventually lead to exhaustion.
NEW QUESTION 293
A 25-year-old lawyer who is married with three young children works long hours in an effort to become a partner in the law firm. Following a recent hospitalization for a bleeding ulcer, he was referred for therapy to treat this psychophysiological disorder. On meeting with the therapist, he informed him or her that he was a busy man and did not have much time for this "psych stuff." When guiding the client to ventilate his feelings, the therapist can expect him to express feelings of:
- A. Anger
- B. Guilt
- C. Shame
- D. Despair
Answer: A
Explanation:
Explanation
(A) Guilt relates to depression. (B) Shame is not associated with psychophysiological disorders. (C) Despair relates to depression. (D) Repressed anger is associated with psychophysiological disorders.
NEW QUESTION 294
A male infant is to be discharged home this morning. Which instruction related to his cord care should be included in his mother's discharge teaching plan?
- A. Clean the umbilical cord with alcohol at each diaper change.
- B. Keep the umbilical area moist with Vaseline until the stump falls off.
- C. Clean the umbilical cord daily with soap and water during the bath.
- D. Keep the umbilical area covered at all times with the diaper.
Answer: A
Explanation:
(A) The umbilical area should be kept dry for healing to occur. Moisture is conducive to bacterial growth and therefore could lead to infection at the site. (B) The diaper should be folded below the cord to allow the cord stump to be exposed to the air for healing. (C) The umbilical cord should be swabbed with alcohol at each diaper change to remove urine and stool and to facilitate the desiccation process through drying. (D) Soap and water should not be used to clean the umbilical area because the area could retain moisture, thus making it susceptible to bacterial growth and infection.
NEW QUESTION 295
A 23-year-old female client is brought to the emergency room by her roommate for repeatedly making superficial cuts on her wrists and experiencing wide mood swings. She is very angry and hostile. Her medical diagnosis is adjustment disorder versus borderline personality disorder. The client comments to the nurse,
"Nobody in here seems to really care about the clients. I thought nurses cared about people!" The client is exhibiting the ego defense mechanism:
- A. Splitting
- B. Rationalization
- C. Reaction formation
- D. Sublimation
Answer: A
Explanation:
Section: Questions Set G
Explanation:
(A) Reaction formation is the development and demonstration of attitudes and/or behaviors opposite to what an individual actually feels. The client's comment does reveal her anger and hostility. (B) Rationalization, another ego defense mechanism, is offering a socially acceptable or seemingly logical explanation to justify one's feelings, behaviors, or motives. The client's comment does not reflect rationalization. (C) Splitting, the viewing of people or situations as either all good or all bad, is frequently used by persons experiencing a disruption in self-concept. This ego defense mechanism is reflective of the individual's inability to integrate the positive and negative aspects of self. (D) Sublimation, the channeling of socially unacceptable impulses and behaviors into more acceptable patterns of behavior, is another ego defense mechanism. The client's comment reveals that she is not engaging in sublimation.
NEW QUESTION 296
A client develops complications following a hysterectomy. Blood cultures reveal Pseudomonas aeruginosa. The nurse expects that the physician would order an appropriate antibiotic to treat
P. aeruginosa such as:
- A. Cefoperazone (Cefobid)
- B. Dicloxacillin (Dycill)
- C. Clindamycin (Cleocin)
- D. Erythromycin (Erythrocin)
Answer: A
Explanation:
Section: Questions Set G
Explanation:
(A) Cefoperazone is indicated in the treatment of infection with Pseudomonas aeruginosa.(B) Clindamycin is not indicated in the treatment of infection withP. aeruginosa.(C) Dicloxacillin is not indicated in the treatment of infection with
P. aeruginosa.(D) Erythromycin is not indicated in the treatment of infection with
P. aeruginosa.
NEW QUESTION 297
The nurse discovers that a 78-year-old client who received hydralazine (Apresoline) 20 mg 45 minutes ago has a blood pressure of 70/40 mm Hg. The client has been on this dose of the medication for 3 years.
Which of the following data is most likely significant in relation to the cause of the low blood pressure?
- A. Pedal pulses 11 (weak)
- B. Serum potassium 3.3
- C. Twenty-four-hour intake 1000 mL/day for past 2 days
- D. Pulse rate 150 bpm
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A, D) Decreased pulse volume and increased pulse rate are signs of an acute hypotensive episode. (B) Inadequate fluid volume when taking vasodilators can result in a drop in blood pressure when vasodilation starts to physiologically occur as an action of the drug. (C) A potassium level of 3.3 would not be associated with a significant drop in blood pressure.
NEW QUESTION 298
A 25-year-old client is admitted for a tonsillectomy. She tells the nurse that she has had episodes of muscle cramps, weakness, and unexplained temperature elevation. Many years ago her father died shortly after surgery after developing a high fever. She further tells the nurse that her surgeon is having her take dantrolene sodium (Dantrium) prophylactically prior to her tonsillectomy. Dantrolene sodium is ordered preoperatively to reduce the risk or prevent:
- A. Malignant hyperthermia
- B. Neuroleptic malignant syndrome
- C. Fever postoperatively
- D. Infection postoperatively
Answer: A
Explanation:
(A, D) Dantrolene sodium is a peripheral skeletal muscle relaxant and would have no effect on a postoperative infection. (B) Dantrolene sodium is indicated prophylactically for clients with malignant hyperthermia or with a family history of the disorder. The mortality rate for malignant hyperthermia is high. (C) Neuroleptic malignant syndrome is an exercise-induced muscle pain and spasm and is unrelated to malignant hyperthermia.
NEW QUESTION 299
A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:
- A. Febrile transfusion reaction
- B. Allergic transfusion reaction
- C. Hemolytic transfusion reaction
- D. Circulatory overload
Answer: B
Explanation:
(A) A hemolytic transfusion reaction would be characterized by fever, chills, chest pain, hypotension, and tachypnea. (B) Fever, chills, and headaches are indicative of a febrile transfusion reaction. (C) Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles. (D) Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion reaction.
NEW QUESTION 300
A female client at 37 weeks' gestation has just undergone a nonstress test. The results were two fetal movements with a corresponding increase in fetal heart rate (FHR) of 15 bpm lasting 15 seconds within a
20-minute period. Her results would be classified as:
- A. Reactive; no contraction stress test required
- B. Non-reactive; no contraction stress test required
- C. Reactive; needs follow-up contraction stress test
- D. Non-reactive; needs follow-up contraction stress test
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) A contraction stress test is unnecessary following a reactive (normal) nonstress test. (B) The results are considered reactive, indicating that the fetus is not showing distress. Therefore, a contraction stress test, which is a more in-depth test for fetal distress, is unnecessary. (C) A nonreactive test would show fewer than two fetal movements or a failure of the FHR to increase at least 15 bpm with the movements in a 20-minute period. (D) A contraction stress test should follow a nonreactive nonstress test to validate fetal distress.
NEW QUESTION 301
The client will be more comfortable and the results more accurate when the nurse prepares the client for Leopold's maneuvers by having her:
- A. Lie on her left side
- B. Empty her bladder
- C. Place her arms over her head
- D. Force fluids 1 hour prior to procedure
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) A full bladder would cause discomfort and possible urinary incontinence during the exam. (B) The left side-lying position would not accommodate the exam. The head of the exam table or bed can be slightly elevated to prevent supine hypotension. (C) Arms extended over the head would cause the abdomen to be tighter and less easily palpable. (D) Forcing fluids would encourage a full bladder, which is not desired for the exam.
NEW QUESTION 302
A dose of theophylline may need to be altered if a client with COPD:
- A. Is allergic to morphine
- B. Operates machinery
- C. Is concurrently on cimetidine for ulcers
- D. Has a history of arthritis
Answer: C
Explanation:
Explanation
(A) The effects of morphine or an allergic response to the drug will not affect theophylline clearance. (B) Xanthines are used cautiously in clients with severe cardiac disease, liver disease, cor pulmonale, hypertension, or hyperthyroidism. Arthritis does not influence the dosage of theophylline. (C) Theophylline does not cause sedation or drowsiness. Conversely, its side effects may be exhibited by central nervous system stimulation. (D) Cimetidine decreases theophylline clearance from the system and increases theophylline levels in the blood, thus increasing the risk of toxicity.
NEW QUESTION 303
A client's wife is concerned over his behavior in recent months. He has been diagnosed with Parkinson's disease, and she is telling his nurse that he has been doing "strange things." The nurse reassures the wife that the following behavior is normal with Parkinson's disease:
- A. "Twitching of the muscles is to be expected and can occur at any time during the day."
- B. "Your husband will experience some periods of muscle flaccidity. Be sure to make him sit down during these periods."
- C. "Parkinson's disease causes severe pain in the joints. You should give your husband Tylenol at those times."
- D. "Your husband may move his hands in motions that look like he is rolling a pill between his fingers."
Answer: D
Explanation:
(A) Clients with Parkinson's disease generally experience stiffness and rigid movement. (B) Pill-rolling movements are a symptom experienced by the Parkinson client. (C) Twitching of the muscles is not an expected symptom of Parkinson's disease. (D) Parkinson's disease does not cause joint pain. Mild muscular pain may be present.
NEW QUESTION 304
A 34-year-old client who is gravida 1, para 0 has a history of infertility and conceived this pregnancy while taking fertility drugs. She is at 32 weeks' gestation and is carrying triplets. She is complaining of low back pain and a feeling of pelvic pressure. Her cervical exam reveals a long, closed cervix. The nurse notes that the client is experiencing mild uterine contractions every 7-8 minutes after the nurse has placed her on the fetal monitor. Her condition should indicate that:
- A. Her cervix shows she will likely deliver soon
- B. The nurse should not be alarmed because mild uterine activity is common at 32 weeks' gestation
- C. She may be in preterm labor because this is more common with multiple pregnancies
- D. She most likely has a urinary tract infection (UTI) because this is common with pregnancy
Answer: C
Explanation:
(A) Her cervical exam is normal. There are no cervical changes at this time. (B) Braxton Hicks contractions may be common throughout pregnancy, but they are not regular. (C) Rhythmical contractions in conjunction with low back pain and pelvic pressure at 32 weeks in a woman carrying triplets are of great concern. She may be in preterm labor. (D) UTIs are common in pregnancy due to the enlarging uterus compressing the ureters and the stasis of urine. The woman would be more likely to complain of urinary frequency and urgency, fever or chills, and malodorous urine with a UTI.
NEW QUESTION 305
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