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NEW QUESTION 410
A client is placed in five-point restraints after exhibiting sudden violence after illegal drug use, and haloperidol (Haldol) 5 mg IM is administered. After 1 hour, his behavior is more subdued, but he tells the nurse, "The devil followed me into this room, I see him standing in the corner with a big knife. When you leave the room, he's going to cut out my heart." The nurse's best response is:
- A. "Try to sleep. When you wake up, the devil will be gone."
- B. "I know you're feeling frightened right now, but I want you to know that I don't see anyone in the corner."
- C. "You're probably feeling guilty because you used illegal drugs tonight."
- D. "You'll probably see strange things for a while until the PCP wears off."
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) The nurse is the client's link to reality. This response validates the authenticity of the client's experience by casting doubt on his belief and reinforcing reality. (B) Although this statement may be literally correct, it is nontherapeutic because it lacks validation. (C) This response encourages the client to attempt to do something that may be impossible at this time, offers false reassurance, and reinforces delusional content.
(D) The nurse is making an incorrect assumption about the client's feelings by offering a nontherapeutic interpretation of the motivation for the client's actions.
NEW QUESTION 411
A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse's most therapeutic response will be:
- A. "I don't see your mother in the room. Let's talk about how you're feeling."
- B. "OK, I'll come back later when you're feeling more like taking your medicine."
- C. "She may be here, but I can't see her."
- D. "Why don't you finish talking to her, and I'll wait."
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) This response uses the principle of reality orientation by the nurse telling the client that he or she does not see anything, but it does recognize his feelings. (B) This response does not make it clear that the nurse does not see anyone else in the room, and the nurse leaves the client alone to continue hallucinating. (C) This response leaves room for doubt; the nurse is further confusing the client by this statement. (D) This response reinforces the hallucination and implies that the nurse sees his mother, too.
NEW QUESTION 412
With a geriatric client, the nurse should also assess whether he has been obtaining a yearly vaccination against influenza. Why is this assessment important?
- A. Older clients have more exposure to the causative agents.
- B. Influenza is growing in our society.
- C. Older clients have less effective immune systems.
- D. Older clients generally are sicker than others when stricken with flu.
Answer: C
Explanation:
Explanation
(A) Although influenza is common, the elderly are more at risk because of decreased effectiveness of their immune system, not because the incidence is increasing. (B) Older clients have the same degree of illness when stricken as other populations. (C) As people age, their immune system becomes less effective, increasing their risk for influenza. (D) Older clients have no more exposure to the causative agents than do school-age children, for example.
NEW QUESTION 413
When assessing a child with diabetes insipidus, the nurse should be aware of the cardinal signs of:
- A. Anemia and vomiting
- B. Polyuria and polydipsia
- C. Hypothermia and azotemia
- D. Irritability relieved by feeding formula
Answer: B
Explanation:
(A) Anemia and vomiting are not cardinal signs of diabetes insipidus. (B) Polyuria and
polydipsia are the cardinal signs of diabetes insipidus. (C) Irritability relieved by feeding water, not formula, is a common sign, but not the cardinal sign, of diabetes insipidus. (D) Hypothermia and azotemia are signs, but not cardinal signs, of diabetes insipidus.
NEW QUESTION 414
Assessment of severe depression in a client reveals feelings of hopelessness, worthlessness; inability to feel pleasure; sleep, psychomotor, and nutritional alterations; delusional thinking; negative view of self; and feelings of abandonment. These clinical features of the client's depression alert the nurse to prioritize problems and care by addressing which of the following problems first:
- A. Rest and activity impairment
- B. Possible harm to self
- C. Impaired thinking
- D. Nutritional status
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Anorexia and weight loss are problems that need attention in severe depression, but they can be addressed secondary to immediate concerns. (B) Impaired thinking and confusion are problems in severe depression that are addressed with administration of medication, through group and individual psychotherapy, and through activity therapy as motivation and interest increase. (C) Possible harm to self as with suicidal ideation; a suicide plan, means to execute plan; and/or overt gestures or an attempt must be addressed as an immediate concern and safety measures implemented appropriate to the risk of suicide. (D) Rest and activity impairment may take time and further assessment to determine client's sleep pattern and amount of psychomotor retardation with the more immediate concern for safety present.
NEW QUESTION 415
A 19-year-old male client arrived via ambulance to the emergency room following a motorcycle accident. He is comatose. His face has evidence of dried blood. On assessment, the nurse notes an obvious injury to his left eye. The preferred positioning for a client with an obvious eye injury is:
- A. Sitting with head support
- B. Side-lying, either left or right
- C. Reclining to control bleeding
- D. Any position in which the client is comfortable
Answer: A
Explanation:
Explanation
(A) A reclining position can cause a penetrating object to advance further into the eye. (B) Prevention of further injury is the priority, not comfort. (C) A side-lying position may increase intraocular and intracranial pressure if an accompanying head injury is suspected. (D) A sitting position with the head supported will prevent further injury while allowing injury care to take place.
NEW QUESTION 416
A 66-year-old female client has smoked 2 packs of cigarettes per day for 20 years. Her arterial blood gases on room air are as follows: pH 7.35; PO2 70 mm Hg; PCO2 55 mm Hg; HCO3 32 mEq/L. These blood gases reflect:
- A. Compensated respiratory alkalosis
- B. Uncompensated respiratory acidosis
- C. Compensated respiratory acidosis
- D. Compensated metabolic acidosis
Answer: C
Explanation:
Explanation
(A) In compensated metabolic acidosis, the pH level is normal, the PCO2level is decreased, and the HCO3level is decreased. The client's primary alteration is an inability to remove excess acid via the kidneys.
The lungs compensate by hyperventilating and decreasing PCO2. (B) In compensated respiratory acidosis, the pH level is normal, the PCO2level is elevated, and the HCO3level is elevated. The client's primary alteration is an inability to remove CO2from the lungs, so over time, the kidneys increase reabsorption of HCO3to buffer the CO2. (C) In compensated respiratory alkalosis, the pH level is normal, the PCO2level is decreased, and the HCO3level is decreased. The client's primary alteration is hyperventilation, which decreases PCO2. The client compensates by increasing the excretion of HCO3from the body. (D) In uncompensated respiratory acidosis, the pH level is decreased, the PCO2level is increased, and the HCO3level is normal. The client's primary alteration is an inability to remove CO2from the lungs. The kidneys have not compensated by increasing HCO3reabsorption.
NEW QUESTION 417
The nurse practitioner determines that a client is approximately 9 weeks' gestation. During the visit, the practitioner informs the client about symptoms of physical changes that she will experience during her first trimester, such as:
- A. Quickening
- B. Abdominal enlargement
- C. A 6-8 lb weight gain
- D. Nausea and vomiting
Answer: D
Explanation:
(A) Nausea and vomiting are experienced by almost half of all pregnant women during the first 3 months of pregnancy as a result of elevated human chorionic gonadotropin levels and changed carbohydrate metabolism. (B) Quickening is the mother's perception of fetal movement and generally does not occur until 18-20 weeks after the last menstrual period in primigravidas, but it may occur as early as 16 weeks in multigravidas. (C) During the first trimester there should be only a modest weight gain of 2-4 lb. It is not uncommon for women to lose weight during the first trimester owing to nausea and/or vomiting. (D) Physical changes are not apparent until the second trimester, when the uterus rises out of the pelvis.
NEW QUESTION 418
On morning rounds, the nurse found a manic-depressive client who is taking lithium in a confused mental state, vomiting, twitching, and exhibiting a coarse hand tremor. Which one of the following nursing actions is essential at this time?
- A. Administer her next dosage of lithium, and then call the physician.
- B. Contact the lab and request a lithium level in 30 minutes, and call the physician.
- C. Withhold her lithium, and report her symptoms to the physician.
- D. Place her on NPO to decrease the excretion of lithium from her body, and call the physician.
Answer: C
Explanation:
Explanation
(A) The client has lithium toxicity, and the nurse must withhold further dosages. (B) Because of her level of toxicity, further lithium could cause coma and death. The nurse needs further orders from the physician to stabilize the client's lithium level. (C) Ensuring adequate intake of sodium chloride will promote excretion of lithium and will assist in managing the client's lithiumtoxicity. (D) A lithium blood level must be drawn immediately to determine the seriousness of the toxicity and to provide the physician with data for medical orders.
NEW QUESTION 419
A client at 6 months' gestation complains of tiredness and dizziness. Her hemoglobin level is 10 g/dL, and her hematocrit value is 32%. Her nutritional intake is assessed as sufficient. The most likely diagnosis is:
- A. Fatigue due to stress
- B. No problem indicated
- C. Physiological anemia
- D. Iron-deficiency anemia
Answer: D
Explanation:
Section: Questions Set F
Explanation:
(A) This clinical situation is indicative of iron-deficiency anemia because the client has inadequate nutritional intake. Her blood volume is increasing faster than her red blood cell volume. Anemia is present in the second trimester when the hemoglobin level is <10.5 and the hematocrit value falls below 35%. She needs increased iron supplements with follow-up. (B) The client's values are below levels for physiological anemia. (C) The client is fatigued because of a low hemoglobin level. (D) Her hemoglobin level is low and will probably decrease even more when the blood volume peaks at 28 weeks.
NEW QUESTION 420
A client is being discharged and will continue enteral feedings at home. Which of the following statements by a family member indicates the need for further teaching?
- A. "I should use prepared or open formula within 24 hours and store unused portions in the refrigerator."
- B. "It is important to keep the head of his bed elevated or sit him in the chair during feedings."
- C. "If he develops diarrhea lasting for more than 2-3 days, I will contact the doctor or nurse."
- D. "I should anticipate that he will gain about 1 lb/day now that he is on continuous feedings."
Answer: D
Explanation:
Section: Questions Set B
Explanation:
(A) Diarrhea is a complication of tube feedings that can lead to dehydration. Diarrhea may be the result of hypertonic formulas that can draw fluid into the bowel. Other causes of diarrhea may be bacterial contamination, fecal impaction, medications, and low albumin. (B) A consistent weight gain of more than 0.22 kg/day (1κΆ€2 lb/day) over several days should be reported promptly. The client should be evaluated for fluid volume excess. (C) Elevating the client's head prevents reflux and thus formula from entering the airway. (D) Bacteria proliferate rapidly in enteral formulas and can cause gastroenteritis and even sepsis.
NEW QUESTION 421
To appropriately monitor therapy and client progress, the nurse should be aware that increased myocardial work and O2 demand will occur with which of the following?
- A. Increase in balance of myocardial O2 supply and demand
- B. Afterload reduction therapy
- C. Negative chronotropic therapy
- D. Positive inotropic therapy
Answer: D
Explanation:
(A)
Inotropic therapy will increase contractility, which will increase myocardial O2 demand.
(B)
Decreased heart rate to the point of bradycardia will increase coronary artery filling time. This should be used cautiously because tachycardia may be a compensatory mechanism to increase cardiac output. (C) The goal in the care of the MI client with angina is to maintain a balance between myocardial O2 supply and demand. (D) Decrease in systemic vascular resistance by drug therapy, such as IV nitroglycerin or nitroprusside, or intra-aortic balloon pump therapy, would decrease myocardial work and O2 demand.
NEW QUESTION 422
A 78-year-old female client has a total hip arthroplasty. Her nurse should know that which of the following is contraindicated?
- A. Place a trochanter roll along the upper thigh of the affected leg.
- B. Encourage exercises in the unaffected extremities.
- C. Encourage her to cross and uncross her legs.
- D. Check neurological and circulatory status of the affected leg hourly.
Answer: C
Explanation:
Explanation
(A) Exercising the unaffected extremities will prevent contractures and emboli. (B) Crossing and uncrossing the affected leg after surgery can dislocate the joint. (C) Neurological and circulatory status of the affected leg has been compromised by surgery. Hourly checks are needed to monitor the status of the leg. (D) A trochanter roll will prevent the upper thigh from rolling outward, increasing the chances of dislocation.
NEW QUESTION 423
A 56-year-old client is admitted to the psychiatric unit in a state of total despair. She feels hopeless and worthless, has a flat affect and very sad appearance, and is unable to feel pleasure from anything. Her husband has been assisting her at home with the housework and cooking; however, she has not been eating much, lies around or sits in a chair most of the day, and is becoming confused and thinks her family does not want her around anymore. In assessing the client, the nurse determines that her behavior is consistent with:
- A. Moderate depression
- B. Transient depression
- C. Severe depression
- D. Mild depression
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Transient depression manifests as sadness or the "blues" as seen with everyday disappointments and is not necessarily dysfunctional. (B) Mild depression manifests as symptoms seen with grief response, such as denial, sadness, withdrawal, somatic symptoms, and frequent or continuous thoughts of the loss.
(C) Moderate depression manifests as feelings of sadness, negativism; low self-esteem; rumination about life's failures; decreased interest in grooming and eating; and possibly sleep disturbances. These symptoms are consistent with dysthymia. (D) Severe depression manifests as feelings of total despair, hopelessness, emptiness, inability to feel pleasure; possibly extreme psychomotor retardation; inattention to hygiene; delusional thinking; confusion; self-blame; and suicidal thoughts. These symptoms are consistent with major depression.
NEW QUESTION 424
A client decided early in her pregnancy to breast-feed her first baby. She gave birth to a normal, full-term girl and is now progressing toward the establishment of successful lactation. To remove the baby from her breast, she should be instructed to:
- A. Compress the areolar tissue until the infant drops the nipple from her mouth
- B. Insert a clean finger into the baby's mouth beside the nipple
- C. Gently pull the infant away
- D. Withdraw the breast from the infant's mouth
Answer: B
Explanation:
Section: Questions Set B
Explanation:
(A) In pulling the infant away from the breast without breaking suction, nipple trauma is likely to occur. (B) In pulling the breast away from the infant without breaking suction, nipple trauma is likely to occur. (C) Compressing the maternal tissue does not break the suction of the infant on the breast and can cause nipple trauma. (D) By inserting a finger into the infant's mouth beside the nipple, the lactating mother can break the suction and the nipple can be removed without trauma.
NEW QUESTION 425
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