QUESTION: "The client finds the chronic tinnitus of Meniere's disease extremely irritating. Which of the following strategies would be best for the nurse to suggest?"
CHOICES
( X ) a.) Maintain a quiet, restful environment.
( O ) b.) Mask the tinnitus with background music.
( X ) c.) Ensure adequate dietary levels of vitamin B 6.
( X ) d.) Recommend a hearing aid.
RATIONALE: The chronic tinnitus associated with Meniere's disease can be extremely intrusive and frustrating for clients. Attempting to mask tinnitus with a low-level competing sound, such as music, is often recommended. Quiet environments appear to worsen the client's perception of the problem. Vitamin B 6 will not affect the tinnitus. A hearing aid is not a treatment for tinnitus. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 1002 _ about (MC)
QUESTION: "Which of the following is an early sign of laryngeal cancer?"
CHOICES
( X ) a.) Difficulty swallowing.
( O ) b.) Persistent mild hoarseness.
( X ) c.) Chronic foul breath.
( X ) d.) Nagging unproductive cough.
RATIONALE: Hoarseness occurs early in the course of most laryngeal cancers because the tumor prevents accurate approximation of the vocal cords during phonation. Large tumors eventually produce difficulty and pain in swallowing, but this is not an early sign. Foul breath and expectoration of blood are late symptoms. A nagging cough has no direct relationship to laryngeal cancer. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1003 _ about (MC)
QUESTION: "A client is scheduled for radical neck surgery and a total laryngectomy. During the preoperative teaching, the nurse should prepare the client for which of the following postoperative possibilities?"
CHOICES
( X ) a.) Endotracheal intubation.
( O ) b.) Insertion of a laryngectomy tube.
( X ) c.) Immediate speech therapy.
( X ) d.) Gastrostomy tube.
RATIONALE: The client may have a temporary laryngectomy tube, which remains in place until the wound is healed and a permanent stoma has formed usually in 2 or 3 weeks. An endotracheal tube is not used because the client's normal airway has been disrupted by surgery. Speech therapy is delayed until edema subsides and healing occurs. After surgery, enteral feedings may be given until edema subsides; however, most clients do not require a gastrostomy tube. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1004 _ about (MC)
QUESTION: "Which of the following is a priority nursing goal for the client immediately after a total laryngectomy?"
CHOICES
( O ) a.) Maintain a patent airway.
( X ) b.) Provide nutrition.
( X ) c.) Prevent strain on suture lines.
( X ) d.) Prevent hemorrhage.
RATIONALE: Maintaining a patent airway is the the priority nursing goal in the immediate postoperative period. The client's ability to cough and deep breathe is impaired because the glottis has been removed. Providing nutrition is an important nursing goal, but maintaining a patent airway is the priority. Reducing strain on suture lines is an important nursing goal, but maintaining a patent airway is the priority. Preventing hemorrhage is an important nursing goal, but maintaining a patent airway is the priority. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1005 _ about (MC)
QUESTION: "The client with a total laryngectomy receives tube feedings to meet his fluid and nutrition needs. What is the primary rationale for tube feedings in this situation?"
CHOICES
( X ) a.) Prevent pain from swallowing.
( X ) b.) Ensure adequate intake.
( X ) c.) Prevent fistula development.
( O ) d.) Allow for adequate suture line healing.
RATIONALE: A nasogastric tube is usually inserted during surgery to allow for enteral feedings postoperatively. The tube allows the suture line to heal adequately, minimizes contamination of the pharyngeal and esophageal suture lines, and prevents fluid from leaking through the wound into the trachea before healing occurs. Normal oral feedings are resumed as soon as the nasogastric tube is removed, usually within 10 days after surgery. Tube feedings do not prevent swallowing or pain upon swallowing. Tube feedings help provide fluid and nutrients during the initial postoperative period; however, the primary rationale for tube feedings after a total laryngectomy is to allow the sutures to heal before providing oral feedings. A tracheoesophageal fistula is a rare potential complication of total laryngectomy and may occur if radiation therapy has compromised wound healing. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
******************************
--> QUESTION NUMBER _ 1006 _ about (MC)
QUESTION: "The development of laryngeal cancer is most clearly linked to which of the following factors?"
CHOICES
( X ) a.) High-fat, low-fiber diet.
( O ) b.) Alcohol and tobacco use.
( X ) c.) Low socioeconomic status.
( X ) d.) Overuse of artificial sweeteners.
RATIONALE: Predisposing factors for laryngeal cancer include chronic irritants such as alcohol, tobacco, and exposure to noxious fumes. About 75% of people who develop laryngeal cancer are smokers. The combination of smoking and heavy alcohol intake is even more strongly implicated as a causative agent in the laryngeal cancer. Epidemiologic studies indicate that a high-fat diet may be a major factor in the development of cancer of the breast, prostate, and colon, but not laryngeal cancer. Low socioeconomic status is a predisposing factor in cervical cancer but not laryngeal cancer. Artificial sweeteners have been related to the incidence of bladder cancer, but not laryngeal cancer. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease
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--> QUESTION NUMBER _ 1007 _ about (MC)
QUESTION: "Which of the following measures should the nurse perform in relation to suctioning a tracheostomy tube?"
CHOICES
( X ) a.) Apply suction while inserting the suction catheter into the tube.
( X ) b.) Change the tracheostomy tube after suctioning the client.
( X ) c.) Select a suction catheter that approximates the diameter of the tracheostomy tube.
( O ) d.) Administer high concentrations of oxygen before suctioning the client.
RATIONALE: Clients are hyperoxygenated before suctioning to prevent hypoxia. Suction is never applied while inserting the catheter into the airway. Laryngectomy tubes are not changed after suctioning. The suction catheter should be about half the diameter of the tube; a larger-diameter suction catheter would interfere with airflow during the procedure. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 1008 _ about (MC)
QUESTION: "To more easily remove thick, tenacious secretions when suctioning a tracheostomy, the nurse should liquefy the secretions before suctioning by instilling the tracheostomy tube with 1 to 2 mL of sterile:"
CHOICES
( X ) a.) Water.
( O ) b.) Normal saline solution.
( X ) c.) Bacteriostatic water.
( X ) d.) Diluted hydrogen peroxide.
RATIONALE: Sterile normal saline is the solution of choice for instillation into a tracheostomy tube cannula to help liquefy sticky secretions. Normal saline solution is less irritating to mucous membranes than plain water, dilute hydrogen peroxide, or bacteriostatic water. Plain water can irritate the mucous membranes. Bacteriostatic water can irritate the mucous membranes. The nurse may cleanse the area around a laryngectomy stoma with an applicator moistened with diluted hydrogen peroxide; care should be taken that no solution enters the stoma because it irritates the respiratory mucosa. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 1009 _ about (MC)
QUESTION: "While suctioning a client's laryngectomy tube, the nurse should insert the catheter :"
CHOICES
( X ) a.) About 1 to 2 inches.
( X ) b.) As the client exhales.
( O ) c.) Until resistance is met, then withdraw it 1 to 2 cm.
( X ) d.) Until the client begins coughing.
RATIONALE: The proper suctioning technique is to insert the suction catheter until resistance is met, withdraw the catheter 1 to 2 cm, then begin applying intermittent suction while withdrawing the catheter. The suction catheter is inserted approximately 5 to 6 inches. It is not necessary to insert the catheter as the client exhales. Coughing by a client does not necessarily indicate when to begin or stop suctioning. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1010 _ about (MC)
QUESTION: "After suctioning a client's tracheostomy tube, the nurse waits a few minutes before suctioning again. The nurse should use intermittent suction primarily to help prevent:"
CHOICES
( X ) a.) Stimulating the client's cough reflex.
( O ) b.) Depriving the client of sufficient oxygen supply.
( X ) c.) Dislodging the tracheostomy tube.
( X ) d.) Obstructing the suctioning catheter with secretions.
RATIONALE: After suctioning, the client should rest at least 3 minutes or until respirations return to normal before suctioning is repeated, unless secretions interfere with breathing. Intermittent suctioning prevents oxygen deprivation. Hypoxia can lead to cardiac dysrhythmias and cardiac arrest. The client should receive 100% oxygen between suctionings. The nurse does not want to prevent stimulating the cough reflex as it helps mobilize secretions. Intermittent suction does not prevent dislodgment of the tracheostomy tube. Intermittent suction does not keep the suction catheter from becoming obstructed; clearing the catheter with normal saline will keep the catheter clear. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 1011 _ about (MC)
QUESTION: "Outcome criteria for evaluating the effectiveness of airway suctioning would include which of the following?"
CHOICES
( X ) a.) Respirations unlabored.
( X ) b.) Hollow sound on chest percussion.
( X ) c.) Decreased mucus production.
( O ) d.) Breath sounds clear on auscultation.
RATIONALE: Auscultating for clear breath sounds is the most accurate way to evaluate the effectiveness of tracheobronchial suctioning. Auscultation should also be done to determine whether or not the client needs suctioning. Assessing for labored respirations is not as accurate in evaluating the effectiveness of tracheobronchial suctioning. A client may have labored breathing that is not affected by the presence or absence of tracheobronchial secretions. Percussion of the chest is useful for detecting masses or dense consolidation of lung tissue. It is not an accurate method for assessing the effectiveness of suctioning. Suctioning clears mucus but does not decrease its production. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
******************************
--> QUESTION NUMBER _ 1012 _ about (MC)
QUESTION: "Which of the following should the nurse include in a postoperative teaching plan for a client with a laryngectomy?"
CHOICES
( X ) a.) Instructing the client to avoid coughing until the sutures are removed.
( X ) b.) Telling the client to speak by covering the stoma with a sterile gauze pad.
( O ) c.) Reassuring the client that normal eating will be possible after healing has occurred.
( X ) d.) Instructing the client to control oral secretions by swabbing them with tissues or by expectorating into an emesis basin.
RATIONALE: Normal eating is possible once the suture line has healed. Coughing is essential to keep the airway patent. Because the larynx has been removed, the ability to speak is lost. Swallowing is usually not affected nor is the ability to control oral secretions. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1013 _ about (MC)
QUESTION: "A client with a new laryngectomy decides to learn about esophageal speech. The speech therapist would explain that this communication technique involves:"
CHOICES
( X ) a.) Holding an electronic instrument against the esophagus.
( X ) b.) Providing an access route from the trachea to the esophagus.
( O ) c.) Filling the esophagus with air.
( X ) d.) Replacing the larynx with scar tissue.
RATIONALE: Esophageal speech requires filling the esophagus with air and allowing it to vibrate out. An artificial larynx (electrolarynx) is a hand-held speech aid placed against the neck. It produces a buzzing sound that can be turned into speech by the tongue and mouth. An access route from the trachea to the esophagus is required for tracheoesophageal shunting. This provides pulmonary power to the pharyngeal sphincter that provides vibrations for a pseudovoice. Replacing the larynx with scar tissue would not facilitate speech because scar tissue is inelastic, nonfunctional tissue. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1014 _ about (MC)
QUESTION: "Which of the following health-promoting activities should the nurse teach the client with a new laryngectomy?"
CHOICES
( O ) a.) Cleanse the mouth three times a day.
( X ) b.) Avoid taking tub baths.
( X ) c.) Develop an aggressive program of exercise to increase airway functioning.
( X ) d.) Dehumidify the air for comfort.
RATIONALE: Oral hygiene is an important aspect of self-care for the laryngectomy client, who is less able to detect mouth odor. Additionally, the mouth harbors bacteria. Good mouth care reduces the risk of infection. The client is able to take tub baths with careful instruction on ways to avoid slipping, the need to make sure the water is no more than 6 inches deep, and other safety measures. Moderate exercise may be beneficial, but an aggressive exercise program is not usually part of the plan of care. Air should be humidified to enhance comfort. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 1015 _ about (MC)
QUESTION: "Which of the following home care activities would be appropriate for a client with a laryngectomy?"
CHOICES
( X ) a.) Keep the stoma opening covered at all times.
( O ) b.) Participate in activities such as walking and golfing.
( X ) c.) Stay inside in an air-conditioned environment in the summer.
( X ) d.) Avoid showering; take tub baths instead.
RATIONALE: The client should be encouraged to participate in activities such as walking, golfing, and other moderate recreational sports. It is not necessary to keep the stoma covered at all times, although a gauze bib can be used to protect the clothes from mucus and to keep irritants from entering the stoma. New laryngectomy clients may find air-conditioning too cool and dry at first so they should avoid such environments. It is not necessary to remain in air-conditioning in the summer. Clients may shower as long as they cover the stoma to prevent water from entering the airway. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 1016 _ about (MC)
QUESTION: "Which of the following would provide the best emergency care for a burn victim at the accident site?"
CHOICES
( O ) a.) Pouring cool water over the burned area.
( X ) b.) Applying clean, dry dressings to the area.
( X ) c.) Rinsing the area with a warm, mild soap solution.
( X ) d.) Applying a mild antiseptic ointment to the area.
RATIONALE: The recommended emergency treatment for a heat burn is immersion in cool water or application of clean, cool wet packs. This treatment helps relieve pain and diminishes tissue damage by cooling the tissue. The burn should be kept moist to prevent the dressing adhering to the wound. Warm, mild soap solutions would be contraindicated because they are irritating to the injured tissue. Antiseptics or ointments are contraindicated because they can lead to further tissue damage. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1017 _ about (MC)
QUESTION: "When bandaging the burned client's hand, the nurse should make certain that:"
CHOICES
( X ) a.) The bandage is free of elastic.
( O ) b.) The hand and finger surfaces do not touch.
( X ) c.) The hand and fingers are not elevated above heart level.
( X ) d.) The bandage material is moistened with sterile normal saline solution.
RATIONALE: When bandaging the client's fingers and hands, the nurse must ensure that skin surfaces do not touch. Allowing skin surfaces to touch interferes with normal healing and is likely to be irritating. Bandages for burns may be elasticized and often are used to form an occlusive pressure dressing. A bandaged hand is ordinarily elevated to prevent edema. The bandages may be impregnated with antimicrobial agents but are not ordinarily kept moist with water or normal saline solution. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1018 _ about (MC)
QUESTION: "Which of the following fluid and electrolyte imbalances would the nurse anticipate that the client would be particularly susceptible to in the emergent phase of burn care?"
CHOICES
( X ) a.) Hemodilution.
( X ) b.) Metabolic alkalosis.
( X ) c.) Hypernatremia.
( O ) d.) Hyperkalemia.
RATIONALE: Owing to the massive cellular destruction that occurs in burns, potassium is released into the extracellular fluid which leads to hyperkalemia. Hemoconcentration is caused by circulatory dehydration as plasma shifts into the extracellular space. Metabolic acidosis commonly develops due to loss of bicarbonate ions. Hyponatremia is another anticipated electrolyte imbalance because sodium is trapped in edematous fluid. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1019 _ about (MC)
QUESTION: "During the first 48 to 72 hours of fluid resuscitation therapy after a major burn injury, the intravenous infusion rate will be adjusted by evaluating the client's:"
CHOICES
( X ) a.) Daily body weight.
( X ) b.) Hourly body temperature.
( O ) c.) Hourly urine output.
( X ) d.) Hourly urine specific gravity.
RATIONALE: During the first 48 to 72 hours of fluid resuscitation therapy, hourly urine output is the most accessible and generally reliable indicator of adequate fluid replacement. Fluid volume is also assessed by monitoring mental status, vital signs, peripheral perfusion, and body weight. Pulmonary artery end-diastolic pressure (PAEDP) and even central venous pressure (CVP) are preferred guides to fluid administration, but urine output is best when PAEDP or CVP are not used. After the first 48 to 72 hours, urine output is a less-reliable guide to fluid needs. The victim enters the diuretic phase as edema reabsorption occurs, and urine output increases dramatically. During the first 48 to 72 hours, fluid replacement is critical and is based on hourly urine output. Daily body weight does not provide enough information on which to base fluid replacement amounts. Body temperature is not a reliable guide for fluid replacement. Intravenous fluid rates will be adjusted to keep urine output greater than 30 mL per hour. Specific gravity measures the kidney' ability to concentrate urine. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1020 _ about (MC)
QUESTION: "When the open method is used for treating burns, which of the following actions should the nurse take to help prevent discomfort caused by air currents over the client's burned skin surfaces?"
CHOICES
( X ) a.) Keep the client well sedated.
( X ) b.) Add humidity to the room air.
( O ) c.) Support the bed linens on a cradle.
( X ) d.) Keep the door and windows closed in the room.
RATIONALE: Bed linens should be kept off a burn wound when the open method of wound care is used. To prevent drafts over the burned areas, it is best to place a cradle on the bed and drape bed linens over the cradle. Keeping the client well sedated does not help prevent discomfort due to air currents passing over burned areas. Adding humidity to the room air does not help prevent discomfort due to air currents passing over burned areas. Keeping doors and windows closed does not help prevent discomfort due to air currents passing over burned areas. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1021 _ about (MC)
QUESTION: "The nurse assesses the client's burned right arm and notes increasing edema, absence of a radial pulse, and decreased sensation in the fingers. Based on these data, the nurse's priority response should be to:"
CHOICES
( X ) a.) Document findings and recheck in 1 hour.
( X ) b.) Elevate extremity on one pillow.
( O ) c.) Notify the physician immediately.
( X ) d.) Implement passive range-of-motion exercises.
RATIONALE: The absence of a pulse, decreased sensation in the extremity, and increasing edema are all indicative of compromised neurovascular status due to compartment syndrome. Loss of pulse or sensation must be reported immediately to the physician. An escharotomy or fasciotomy may need to be performed to release pressure in the extremity. Other assessments to note include the temperature, capillary refill time, and movement or increasing pain of the affected extremity. Compartment syndrome is an urgent situation. Delay in treatment, even by one hour, can result in permanent disability. Although elevating the extremity may help to decrease edema, this situation requires aggressive treatment by a surgeon. Passive range-of-motion exercises will not have an effect on compartment syndrome. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1022 _ about (MC)
QUESTION: "While caring for the client with a burn injury, the nurse should observe for signs and symptoms of which complication believed to be due primarily to hypersecretion of gastric acid?"
CHOICES
( X ) a.) Paralytic ileus.
( X ) b.) Gastric distention.
( X ) c.) Hiatal hernia.
( O ) d.) Gastrointestinal ulceration.
RATIONALE: Gastrointestinal ulceration, also known as Curling's ulcer, occurs in about half of clients suffering from severe burns. The incidence of ulceration appears proportional to the extent of the burns and is believed to be due to hypersecretion of gastric acid and compromised gastrointestinal perfusion. Paralytic ileus is not caused by hypersecretion of gastric acid. Gastric distention is not caused by hypersecretion of gastric acid. Hiatal hernia is not caused by hypersecretion of gastric acid. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1023 _ about (MC)
QUESTION: "When instructing the client with severe burns about proper nutrition, the nurse would encourage him to eat which of the following meals?"
CHOICES
( X ) a.) Chicken breast, salad, iced tea.
( O ) b.) Roast beef sandwich, milkshake, cottage cheese.
( X ) c.) Hamburger, orange, coffee.
( X ) d.) Pasta salad, carrots, milk.
RATIONALE: A roast beef sandwich, milkshake, and cottage cheese would provide the burn victim with the extra protein and calories needed for healing. This meal provides fewer calories and less protein than is optimal and would not be the preferred choice for the client with severe burns. This meal provides fewer calories and less protein than is optimal and would not be the preferred choice for the client with severe burns. This meal provides fewer calories and less protein than is optimal and would not be the preferred choice for the client with severe burns. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1024 _ about (MC)
QUESTION: "An autograft is taken from the client's left leg. The nurse should care for the donor site by:"
CHOICES
( X ) a.) Covering it with an occlusive dry dressing.
( O ) b.) Keeping the site clean and dry.
( X ) c.) Applying a pressure dressing.
( X ) d.) Wrapping the extremity with an elastic bandage.
RATIONALE: It is important to keep donor sites clean, dry, and free of pressure. Single-layer gauze dressings impregnated with petroleum, scarlet red, or biosynthetic dressings may be used to cover the donor site as it heals. If cared for properly, the site usually heals in 1 to 2 weeks. Occlusive dressings are not used because they do not keep the donor site dry and open to the air. A pressure dressing is not needed over the donor site and can impair healing. Elastic bandages are not used because they constrict circulation and can impede healing. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1041 _ about (MC)
QUESTION: "A client is receiving cefazolin (Kefzol) 1 g every 6 hours intravenously. The medication label reads 1 g in 50 mL of normal saline to infuse over 30 min. (Drop factor 10 gtts/1 mL). What is the correct rate of infusion?"
CHOICES
( X ) a.) 10 gtts/min.
( O ) b.) 17 gtts/min.
( X ) c.) 25 gtts/min.
( X ) d.) 30 gtts/min.
RATIONALE: Rate of infusion is calculated by volume to be infused multiplied by drops per ml/total minutes. 50 mL x 10 gtt / 30 min = 16.6 gtts/min (17). Rate of infusion is calculated by volume to be infused multiplied by drops per mL/total minutes. 50 mL x 10 gtt / 30 min = 16.6 gtts/min
(17). (17). Rate of infusion is calculated by volume to be infused multiplied by drops per ml/total minutes. 50 mL x 10 gtt / 30 min = 16.6 gtts/min (17). Rate of infusion is calculated by volume to be infused multiplied by drops per ml/total minutes. 50 mL x 10 gtt / 30 min = 16.6 gtts/min (17). NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1042 _ about (MC)
QUESTION: "A client has carbamazepine (Tegretol) 450 mg ordered. The nurse has available a liquid suspension that contains 100 mg/5 mL. How many mL should the nurse prepare to administer?"
CHOICES
( X ) a.) 10.5 mL.
( X ) b.) 20 mL.
( O ) c.) 22.5 mL.
( X ) d.) 30 mL.
RATIONALE: 450 mg/x mL = 100 mg/5 mL x = 22.5 mL. 450 mg/x mL = 100 mg/5 mL x = 22.5 mL. 450 mg/x mL = 100 mg/5 mL x = 22.5 mL. 450 mg/x mL = 100 mg/5 mL x = 22.5 mL. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1043 _ about (MC)
QUESTION: "Oxtriphylline (Choledyl SA) 0.2 g has been ordered. Available tablets are 100 mg. How many tablets should be given?"
CHOICES
( X ) a.) 0.5 tablets.
( O ) b.) 2.0 tablets.
( X ) c.) 2.5 tablets.
( X ) d.) 5.0 tablets.
RATIONALE: Convert grams to milligrams. 0.2 g = 200 mg. 200 mg/x tablets = 100 mg/1 tablet x = 2 tablets. Convert grams to milligrams. 0.2 g = 200 mg. 200 mg/x tablets = 100 mg/1 tablet x = 2 tablets. Convert grams to milligrams. 0.2 g = 200 mg. 200 mg/x tablets = 100 mg/1 tablet x = 2 tablets. Convert grams to milligrams. 0.2 g = 200 mg. 200 mg/x tablets = 100 mg/1 tablet x = 2 tablets. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1044 _ about (MC)
QUESTION: "Promethazine hydrochloride (Phenergan) 20 mg IM is ordered for the client's nausea. The ampule label reads 25 mg/mL. How many mL should the nurse give?"
CHOICES
( X ) a.) 0.25 mL.
( X ) b.) 0.5 mL.
( O ) c.) 0.8 mL.
( X ) d.) 1.25 mL.
RATIONALE: 20 mg/x mL = 25 mg/1 mL x = 0.8 mL. 20 mg/x mL = 25 mg/1 mL x = 0.8 mL. 20 mg/x mL = 25 mg/1 mL x = 0.8 mL. 20 mg/x mL = 25 mg/1 mL x = 0.8 mL. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1045 _ about (MC)
QUESTION: "The client is ordered 1000 mL D5/NS to be given over 8 hours. The infusion set delivers 10 gtts/mL. What is the flow rate for the IV?"
CHOICES
( O ) a.) 21 gtts/min.
( X ) b.) 33 gtts/min.
( X ) c.) 40 gtts/min.
( X ) d.) 50 gtts/min.
RATIONALE: 10 gtts/mL x 1000 mL/480 min = 21 gtts/min. 10 gtts/mL x 1000 mL/480 min = 21 gtts/min. 10 gtts/mL x 1000 mL/480 min = 21 gtts/min. 10 gtts/mL x 1000 mL/480 min = 21 gtts/min. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1046 _ about (MC)
QUESTION: "The nurse has an order to administer scopolamine 0.3 mg IM. The medication is available in a vial that contains 0.4 mg/mL. How many milliliters should the nurse prepare for administration?"
CHOICES
( X ) a.) 0.35 mL.
( X ) b.) 5.5 mL.
( O ) c.) 0.75 mL.
( X ) d.) 1.25 mL.
RATIONALE: 0.4 mg/mL = 0.3mg/x mL x = 0.75 mL. 0.4 mg/mL = 0.3mg/x mL x = 0.75 mL. The nurse should automatically question such a high volume of the medication. 0.4 mg/mL = 0.3mg/x mL x = 0.75 mL. 0.4 mg/mL = 0.3mg/x mL x = 0.75 mL. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1047 _ about (MC)
QUESTION: "A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions would be appropriate for the nurse to give the client for promoting circulation to the extremities?"
CHOICES
( X ) a.) Keep the extremities elevated slightly.
( O ) b.) Participate in a regular walking program.
( X ) c.) Use a heating pad to promote warmth.
( X ) d.) Massage calf muscles if pain occurs.
RATIONALE: Clients diagnosed with peripheral arterial occlusive disease should be encouraged to participate in a regular walking program to help develop collateral circulation. They should be advised to rest if pain develops and resume activity when pain subsides. With arterial disease, extremities should be kept in a dependent position to promote circulation; elevation of the extremities will decrease circulation. To avoid burns, heating pads should not be used by anyone with impaired circulation. Massaging the calf muscles will not decrease pain. Intermittent claudication subsides with rest. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
******************************
--> QUESTION NUMBER _ 1048 _ about (MC)
QUESTION: "Which abnormal laboratory value is most indicative of aplastic anemia?"
CHOICES
( O ) a.) A decreased hemoglobin.
( X ) b.) An elevated white blood cell count.
( X ) c.) An elevated red blood cell count.
( X ) d.) A decreased erythrocyte sedimentation rate.
RATIONALE: A decreased hemoglobin is indicative of aplastic anemia. In addition to a decreased hemoglobin and red blood cell count, the client will also have a decreased white blood cell count and decreased platelets. The white blood count is decreased, not elevated. The red blood count is decreased, not elevated. Erythrocyte sedimentation rates are elevated in the presence of inflammation and may be elevated in anemia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
******************************
--> QUESTION NUMBER _ 1049 _ about (MC)
QUESTION: "The nurse is assessing the breath sounds of a client with emphysema. The nurse understands that the client's respiratory status is affected by what primary pathophysiologic changes?"
CHOICES
( X ) a.) Constricted airspaces in the lungs.
( O ) b.) Destruction of alveolar walls.
( X ) c.) Elevation of the diaphragm.
( X ) d.) Increased airflow out of the lungs.
RATIONALE: Emphysema is characterized by destruction of the alveolar walls, hyperinflation of the alveoli, and loss of lung elasticity. Airspace is not constricted as air can flow easily into the lungs. The diaphragm becomes flattened due to the hyperinflated lungs. The air becomes trapped due to the loss of elasticity and airflow going out of the lungs is decreased. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
******************************
--> QUESTION NUMBER _ 1050 _ about (MC)
QUESTION: "A client is taking spironlactone (Aldactone). Which of the following dietary alterations should the nurse teach the client to make as a result of taking this drug?"
CHOICES
( X ) a.) Restrict sodium intake.
( O ) b.) Avoid eating foods high in potassium.
( X ) c.) Maintain a fluid intake of 3000 mL/day.
( X ) d.) Incorporate iron-rich foods into the diet.
RATIONALE: Spironlactone is a potassium-sparing diuretic that causes excretion of sodium. When taking this drug, it is important that the client not eat foods high in potassium to avoid elevating serum potassium levels. The client does not need to restrict sodium intake as the drug promotes sodium excretion. Unless contraindicated, the client needs to maintain an adequate fluid intake; however, the client does not need to increase fluid intake to 3000 mL/day. Spironlactone does not affect iron levels. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1051 _ about (MC)
QUESTION: "A client is to take cotrimoxazole (Bactrim) for an urinary tract infection. Which of the following statements indicates that the client knows how to correctly take the medication? "
CHOICES
( X ) a.) "I will take the pills until my symptoms disappear."
( O ) b.) "I will need to get a urine culture when I am finished taking the pills."
( X ) c.) "I should decrease my fluid intake to increase the concentration of the drug in my urine."
( X ) d.) "I should take all the pills and then have the prescription renewed if I still have symptoms."
RATIONALE: After completing the drug therapy, it will be necessary to obtain a urine culture to accurately determine the effectiveness of the antibiotic. It is possible for symptoms to be relieved, but bacteria to still be present in the urine. The client should complete the full course of prescribed therapy and not stop taking the drug because symptoms have disappeared. The client should increase fluid intake, not decrease it, in order to dilute the urine and keep the urinary tract flushed. If the client still has symptoms after taking all the prescribed pills, she needs to return to her health care provider for follow-up care. It is likely that another antibiotic needs to be prescribed as the organism may not have been sensitive to cotrimoxazole. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1052 _ about (MC)
QUESTION: "The nurse assesses a client taking chlorpropamide (Diabenese) for which of the following conditions?"
CHOICES
( X ) a.) Dumping syndrome.
( X ) b.) Extrapyramidal symptoms.
( O ) c.) Hypoglycemia.
( X ) d.) Oral candidiasis.
RATIONALE: Chlorpropamide is an antidiabetic agent. Clients should be observed for signs and symptoms of hypoglycemia. Other common side effects include anorexia, nausea, vomiting and heartburn. The drug does not cause the dumping syndrome. Extrapyramidal symptoms are not caused by chlorpropamide. The drug does not cause oral candidiasis. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1053 _ about (MC)
QUESTION: "The client is taking carbamazepine (Tegretol) to treat his trigeminal neuralgia. Which of the following instructions should the nurse include in the client's teaching plan?"
CHOICES
( O ) a.) Arrange to have a CBC drawn weekly.
( X ) b.) Take the drug on an empty stomach.
( X ) c.) Limit physical activity while taking the drug.
( X ) d.) Eliminate caffeine from the diet while taking drug.
RATIONALE: Carbamazepine (Tegretol) can cause potentially fatal hematological disorders. To detect pancytopenia, it is important that the client have weekly CBC checks during the first few months of therapy. The client should be told to report any indications of bone marrow depression such as bleeding, easy bruising, sore throat, fever, or mouth ulcers. Carbamazepine should be taken with food. There is no reason to limit activity while taking carbamazepine. There is no reason to eliminate caffeine while taking carbamazepine. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1054 _ about (MC)
QUESTION: "A client has been placed on levodopa to treat his Parkinson's disease. Which of the following is a common side effect of levodopa that the nurse should include in the client's teaching plan?"
CHOICES
( X ) a.) Pancytopenia.
( X ) b.) Peptic ulcer.
( O ) c.) Postural hypotension.
( X ) d.) Weight loss.
RATIONALE: Postural hypotension resulting in lightheadedness, dizziness, and fainting is a common side effect of levodopa. Clients should be taught to change positions slowly. Levodopa does not commonly cause pancytopenia. Levodopa does not commonly cause peptic ulcer formation. Levodopa does not commonly cause weight loss. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1055 _ about (MC)
QUESTION: "A client diagnosed with hyperthyroidism has been started on propylthiouracil (PTU) as drug therapy. The nurse should closely observe the client for which of the following side effects?"
CHOICES
( O ) a.) Unusual bleeding or bruising.
( X ) b.) Hypertension.
( X ) c.) Hypokalemia.
( X ) d.) Peripheral edema.
RATIONALE: When taking propylthiouracil (PTU), the client should report any unusual bleeding or bruising as this drug can cause bone marrow depression. Blood tests should be scheduled regularly to detect any hematological changes early. Hypertension is not a side effect of propylthiouracil (PTU). Hypokalemia is not a side effect of propylthiouracil (PTU). Peripheral edema is not a side effect of propylthiouracil (PTU). NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1056 _ about (MC)
QUESTION: "The client is taking triamcinolone acetonide (Azmacort) inhalant to treat her bronchial asthma. Which of the following conditions is the client at increased risk for developing while taking this medication?"
CHOICES
( O ) a.) Oral candidiasis.
( X ) b.) Hyperglycemia.
( X ) c.) Gastric ulcer.
( X ) d.) Fluid retention.
RATIONALE: Azmacort inhalant is a corticosteroid. Use of a steroid inhalers can cause the client to develop oral candidiasis (thrush). It is important that the client rinse his or her mouth after use of the inhaler. Azmacort inhalant does not lead to the development of systemic complications such as hyperglycemia. Azmacort inhalant does not lead to the development of systemic complications such as ulcers. Azmacort inhalant does not lead to the development of systemic complications such as fluid retention. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1057 _ about (MC)
QUESTION: "What would be the flow rate for 1000 mL D5/NS to be given over 6 hours? The infusion set administers 15 gtts/mL."
CHOICES
( X ) a.) 28 gtts/min.
( X ) b.) 35 gtts/min.
( O ) c.) 42 gtts/min.
( X ) d.) 45 gtts/min.
RATIONALE: The IV flow rate is determined by the rate of infusion and the number of drops/mL of the fluid being administered. 15 gtts/mL x 1000 mL/360 min = 42 gtts/min. The IV flow rate is determined by the rate of infusion and the number of drops/mL of the fluid being administered. 15 gtts/mL x 1000 mL/360 min = 42 gtts/min. The IV flow rate is determined by the rate of infusion and the number of drops/mL of the fluid being administered. 15 gtts/mL x 1000 mL/360 min = 42 gtts/min. The IV flow rate is determined by the rate of infusion and the number of drops/mL of the fluid being administered. 15 gtts/mL x 1000 mL/360 min = 42 gtts/min. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1058 _ about (MC)
QUESTION: "A nurse is to give a client Heparin 8000 units subcutaneously. The available vial is 10,000 units/mL. How many milliliters should the nurse draw up into the syringe?"
CHOICES
( X ) a.) 0.5 mL.
( O ) b.) 0.8 mL.
( X ) c.) 1.0 mL.
( X ) d.) 1.2 mL.
RATIONALE: 8000 units/x mL = 10,000 units/mL x = 0.8 mL. 8000 units/x mL = 10,000 units/mL x = 0.8 mL. 8000 units/x mL = 10,000 units/mL x = 0.8 mL. 8000 units/x mL = 10,000 units/mL x = 0.8 mL. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1059 _ about (MC)
QUESTION: "The nurse is to infuse 1000 mL of D5 1/2 NS over 6 hours. The administration set has a drop factor of 15 gtt/mL. At what rate should the nurse plan to infuse the fluid?"
CHOICES
( X ) a.) 18 gtt/min.
( X ) b.) 21 gtt/min.
( X ) c.) 35 gtt/min.
( O ) d.) 42 gtt/min.
RATIONALE: Multiply total volume to be infused by the drop factor; divide by the total time of infusion in minutes. 1000 mL x 15 gtt / 360 min = 42 gtt/min. Multiply total volume to be infused by the drop factor; divide by the total time of infusion in minutes. 1000 mL x 15 gtt / 360 min = 42 gtt/min. Multiply total volume to be infused by the drop factor; divide by the total time of infusion in minutes. 1000 mL x 15 gtt / 360 min = 42 gtt/min. Multiply total volume to be infused by the drop factor; divide by the total time of infusion in minutes. 1000 mL x 15 gtt / 360 min = 42 gtt/min. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1060 _ about (MC)
QUESTION: "On the first postoperative day after a total hip replacement, the nurse is preparing an elderly client to get out of bed. Which of the following activities would be most helpful to the client?"
CHOICES
( O ) a.) Demonstrate the use of a walker with partial weight bearing.
( X ) b.) Explain to the client that she will be lifted out of bed to a chair.
( X ) c.) Reassure the client that she will be assisted to walk to the hall.
( X ) d.) Demonstrate the swing-through crutch-walking gait with limited weight bearing.
RATIONALE: It would be most helpful to demonstrate the use of a walker with partial weight bearing. Partial weight bearing will be required while the hip is healing. The client will be expected to stand with assistance at the side of the bed the first day postoperative; she will not be lifted to a chair. The client will most likely be expected to take only a few steps the first day, not walk to the hall. The walker provides more stability than crutches for elderly clients. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
******************************
--> QUESTION NUMBER _ 1061 _ about (MC)
QUESTION: "A client is scheduled to undergo an abdominal perineal resection with a permanent colostomy. Which of the following measures would be an anticipated part of the client's preoperative care?"
CHOICES
( X ) a.) Keep the client NPO for 24 hours before surgery.
( O ) b.) Administer neomycin sulfate the evening before surgery.
( X ) c.) Inform the client that total parenteral nutrition will likely be implemented after surgery.
( X ) d.) Advise the client to limit physical activity.
RATIONALE: Antibiotics such as neomycin sulfate will be administered preoperatively to decrease the colon's bacterial count. The client may be placed on a full liquid diet to help cleanse the bowel prior to surgery but is not typically placed on NPO until 8 to 12 hours before surgery. Laxatives and enemas may also be administered. Total parenteral nutrition would not be routinely anticipated postoperatively unless the client had previous nutritional deficits. The client should be encouraged to ambulate before surgery. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
******************************
--> QUESTION NUMBER _ 1062 _ about (MC)
QUESTION: "A 20-year-old client with hepatitis A expresses concern that he may have transmitted the hepatitis to his roommates. Which of the following is recommended for prophylactic treatment of people exposed to hepatitis A?"
CHOICES
( X ) a.) Amphotericin B.
( X ) b.) Interferon.
( X ) c.) Hepatitis A vaccine.
( O ) d.) Immune serum globulin.
RATIONALE: Immune serum globulin is recommended for prophylactic administration to people who have been exposed hepatitis A and not previously vaccinated against it. Amphotericin B is an antifungal antibiotic and is not effective with viral hepatitis. Interferon is an antineoplastic agent used to treat various forms of cancer. In 1995, a vaccine for hepatitis A was approved for people over the age of 2 and is estimated to give 20 years protection against hepatitis A. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1063 _ about (MC)
QUESTION: "Which of the following statements indicates a client understands the nutritional modifications she needs to make because of her Crohn's disease?"
CHOICES
( X ) a.) "I may have cola drinks with my meals."
( X ) b.) "I am allowed to have two to three glasses of wine weekly."
( O ) c.) "A diet high in vitamins and protein is important."
( X ) d.) "I can enjoy peanuts for an evening snack."
RATIONALE: A client with Crohn's disease should follow a diet that is low in residue and high in calories, protein, and vitamins. Because of the involvement of the small bowel in Crohn's disease, it may be difficult for the client to absorb needed nutrients. It is recommended that the client avoid caffeinated drinks. It is recommended that the client avoid alcoholic beverages. Nuts are not recommended on a low-residue diet. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
******************************
--> QUESTION NUMBER _ 1064 _ about (MC)
QUESTION: "A client with aplastic anemia is instructed to eat foods rich in iron. Which of the following foods should the client include in her diet to increase iron intake?"
CHOICES
( X ) a.) Fresh fruits.
( X ) b.) Cheese.
( O ) c.) Dark green leafy vegetables.
( X ) d.) Poultry.
RATIONALE: Foods high in iron include dark green leafy vegetables, liver and red meat, eggs, dried fruit, legumes, and whole grain breads. Fruits are not high in iron. Chese is not high in iron. Poultry is not high in iron. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
******************************
--> QUESTION NUMBER _ 1065 _ about (MC)
QUESTION: "The nurse is preparing to administer meperidine (Demerol) 50 mg IM to a client for pain relief. The available dosage is 75 mg/mL. How many milliliters should the nurse prepare for injection?"
CHOICES
( X ) a.) 0.50 mL.
( O ) b.) 0.67 mL.
( X ) c.) 0.75 mL.
( X ) d.) 1.5 mL.
RATIONALE: 50 mg/ x mL = 75 mg/1 mL. x mL = 0.67 mL. 50 mg/ x mL = 75 mg/1 mL. x mL = 0.67 mL. 50 mg/ x mL = 75 mg/1 mL. x mL = 0.67 mL. 50 mg/ x mL = 75 mg/1 mL. x mL = 0.67 mL. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1066 _ about (MC)
QUESTION: "Which of the following postoperative complications would the nurse particularly anticipate in a client who has had major pelvic surgery?"
CHOICES
( O ) a.) Thrombophlebitis.
( X ) b.) Ascites.
( X ) c.) Peripheral edema.
( X ) d.) Hypostatic pneumonia.
RATIONALE: Clients who have had major pelvic surgery are especially at risk for developing thrombophlebitis postoperatively. Extensive manipulation of the pelvic organs and removal of lymph glands can lead to edema, stasis, and circulatory congestion. This is not a complication that would be specifically anticipated after pelvic surgery. This is not a complication that would be specifically anticipated after pelvic surgery. This is not a complication that would be specifically anticipated after pelvic surgery. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 1067 _ about (MC)
QUESTION: "A client has been prescribed propantheline (Pro-Banthine) as part of the treatment for his peptic ulcer. Which of the following is a medication side effect for which the nurse should evaluate the client?"
CHOICES
( O ) a.) Nausea.
( X ) b.) Hypotension.
( X ) c.) Urinary frequency.
( X ) d.) Fatigue.
RATIONALE: A common side effect of propantheline, an anticholinergic, is nausea. Other common side effects include blurred vision, dry mouth, vomiting, and urinary retention. Propantheline does not cause hypotension. Urinary retention, not frequency, is a common side effect of propantheline. Propantheline does not cause fatigue. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1068 _ about (MC)
QUESTION: "A client is taking sulfamethoxazole (Gantanol) to treat her urinary tract infection. The nurse should plan to include which of the following instructions in the client's teaching plan?"
CHOICES
( X ) a.) "Be sure to take this medication with food."
( O ) b.) "It is important to drink at least 8 glasses of water a day while on this drug."
( X ) c.) "Weigh yourself daily as this drug can cause fluid retention."
( X ) d.) "If you become constipated with this medication, it is okay to take a stool softener."
RATIONALE: Sulfamethoxazole is a very insoluble drug and requires large amounts of fluid intake. Sulfamethoxazole should be taken on an empty stomach with a full glass of water. Sulfamethoxazole drug does not cause fluid retention. It may cause nausea, vomiting, or diarrhea. Sulfamethoxazole drug does not cause constipation. It may cause nausea, vomiting, or diarrhea. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1069 _ about (MC)
QUESTION: "The nurse has administered mannitol IV. Which of the following is a priority assessment for the nurse to make after administering this drug?"
CHOICES
( X ) a.) Monitor serum calcium levels.
( X ) b.) Assess for presence of bowel sounds.
( X ) c.) Check reaction of pupils to light.
( O ) d.) Monitor urinary output.
RATIONALE: Mannitol is an osmotic diuretic used in acute clinical situations. It increases osmotic pressure and draws fluid into the vascular space. Monitoring hourly urinary output is a priority nursing assessment when administering mannitol. Electrolyte levels should also be monitored, most specifically sodium, chloride, and potassium. Calcium levels are not affected by mannitol. This is not a priority nursing assessment when administering mannitol. This is not a priority nursing assessment when administering mannitol. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1070 _ about (MC)
QUESTION: "A client who has been experiencing angina has a new prescription for nitroglycerin. Which of the following should the nurse include in teaching about the side effects of nitroglycerin?"
CHOICES
( O ) a.) Headache.
( X ) b.) Shortness of breath.
( X ) c.) Bradycardia.
( X ) d.) Hypertension.
RATIONALE: The most common side effect of nitroglycerin is a headache. Additional cardiovascular side effects include tachycardia, hypotension, and dizziness. Nitroglycerin does not cause shortness of breath. Nitroglycerin causes tachycardia, not bradycardia. Nitroglycerin causes hypotension, not hypertension. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1071 _ about (MC)
QUESTION: "The nurse is observing a new graduate nurse instill eye drops into a client's eyes. The nurse evaluates that the new graduate is using appropriate technique when which of the following steps is incorporated into the procedure?"
CHOICES
( X ) a.) The client is instructed to apply pressure to the eyes after instillation of the eye drops.
( O ) b.) The nurse's hand is stabilized on the client's forehead while instilling the drops.
( X ) c.) The medication is placed onto the client's sclera.
( X ) d.) The client is instructed to look at the nurse while the drops are being instilled.
RATIONALE: Correct technique for instilling eye drops includes the nurse bracing his or her hand on the client's forehead while instilling the medication. The client should be instructed to gently apply pressure over the inner canthus to prevent systemic absorption of the drug but is not told to apply pressure to the eyes. The medication should be instilled in the client's lower conjunctival sac. To protect the cornea, the nurse should instruct the client to look up while the drops are being instilled. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care
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--> QUESTION NUMBER _ 1072 _ about (MC)
QUESTION: "The nurse has given a client a nitroglycerin tablet sublingually for angina. Which of the following vital signs should be assessed following administration of nitroglycerin?"
CHOICES
( X ) a.) Pulse rate.
( X ) b.) Skin color.
( X ) c.) Respiratory rate.
( O ) d.) Blood pressure.
RATIONALE: Nitroglycerin can cause hypotension. A priority nursing assessment after the administration of nitroglycerin is the client's blood pressure. This is not a priority nursing assessment after the administration of nitroglycerin. This is not a priority nursing assessment after the administration of nitroglycerin. This is not a priority nursing assessment after the administration of nitroglycerin. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1073 _ about (MC)
QUESTION: "Levothyroxine (Synthroid) 0.2 mg orally has been ordered for a client diagnosed with hypothyroidism. The nurse has available 0.05 mg tablets. How many tablets should the nurse prepare to give the client?"
CHOICES
( X ) a.) 2 tablets.
( X ) b.) 3 tablets.
( O ) c.) 4 tablets.
( X ) d.) 5 tablets.
RATIONALE: 0.2 mg/ x tablet = 0.05/ 1 tablet. x = 4 tablets. 0.2 mg/ x tablet = 0.05/ 1 tablet. x = 4 tablets. 0.2 mg/ x tablet = 0.05/ 1 tablet. x = 4 tablets. 0.2 mg/ x tablet = 0.05/ 1 tablet. x = 4 tablets. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1074 _ about (MC)
QUESTION: "Promethazine hydrochloride (Phenergan) 35 mg IM is ordered for a client who is experiencing nausea and vomiting after surgery. The ampule's label reads 25 mg/mL. How many milliliters should the nurse prepare to administer?"
CHOICES
( X ) a.) 0.70 mL.
( X ) b.) 1.0 mL.
( O ) c.) 1.4 mL.
( X ) d.) 1.8 mL.
RATIONALE: 35 mg/x mL = 25 mg/ mL x = 1.4 mL. 35 mg/x mL = 25 mg/ mL x = 1.4 mL. 35 mg/x mL = 25 mg/ mL x = 1.4 mL. 35 mg/x mL = 25 mg/ mL x = 1.4 mL. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1075 _ about (MC)
QUESTION: "A young woman would like to lower her risk for developing cancer and is following a low-fat diet. Which type of cancer is
CHOICES
( O ) a.) Breast cancer.
( X ) b.) Colon cancer.
( X ) c.) Prostate cancer.
( X ) d.) Rectal cancer.
RATIONALE: Based on experimental research that is controversial, breast cancer is not thought to be associated with high dietary fat intake. Current research indicates that high-fat diets are associated with colon, prostate, and rectal cancers. Current research indicates that high-fat diets are associated with colon, prostate, and rectal cancers. Current research indicates that high-fat diets are associated with colon, prostate, and rectal cancers. Current research indicates that high-fat diets are associated with colon, prostate, and rectal cancers. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
******************************
--> QUESTION NUMBER _ 1076 _ about (MC)
QUESTION: "The nurse instructs the female client concerning hormone replacement therapy for menopausal symptoms. Which of the following statements would be important to include in the client's teaching plan?"
CHOICES
( O ) a.) Estrogen therapy can reduce the risk of menopausal bone loss.
( X ) b.) The risk of uterine cancer is decreased after menopause.
( X ) c.) Smoking is associated with a later onset of menopause.
( X ) d.) Estrogen therapy eliminates the need for supplemental calcium intake.
RATIONALE: Research studies have demonstrated that estrogen has been effective in decreasing bone loss. The risk of uterine cancer increases with aging. Smoking is associated with earlier menopause. Estrogen therapy does not eliminate the need for calcium supplements. Calcium supplements should total 1500 mg of calcium daily. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1078 _ about (MC)
QUESTION: "The nurse is teaching a husband how to care for his wife with Alzheimer's disease at home. The nurse emphasizes that the most important environmental factor in aiding the function of clients with Alzheimer's disease is:"
CHOICES
( X ) a.) Variety.
( X ) b.) Unrestricted wandering.
( O ) c.) Consistency.
( X ) d.) Stimulation.
RATIONALE: Clients with Alzheimer's disease need a consistent environment. Consistency assists the client to adjust to the memory loss, time and spatial disorientation, and personality changes that occur with Alzheimer's. Behavioral management of Alzheimer's includes limiting variety in the client's environment. Unrestricted wandering is unsafe for the client with Alzheimer's. Behavioral management of Alzheimer's includes limiting stimulation in the client's environment. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care
******************************
--> QUESTION NUMBER _ 1079 _ about (MC)
QUESTION: "When undertaking diabetic teaching, the nurse understands that the earliest manifestation of diabetic nephropathy is:"
CHOICES
( X ) a.) Polyuria.
( X ) b.) Ketonuria.
( O ) c.) Asymptomatic proteinuria.
( X ) d.) Increasing glycosuria.
RATIONALE: Asymptomatic proteinuria is an initial sign of diabetic nephropathy. Microscopic proteinuria should be monitored yearly in all clients with diabetes for over 5 years. Polyuria is a symptom of poorly managed diabetes. Ketonuria is a sign of diabetic ketoacidosis. Increasing glycosuria is a symptom of poorly managed diabetes. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 1080 _ about (MC)
QUESTION: "The nurse is discussing a treatment plan for mononucleosis with an adolescent. The nurse emphasizes that the client must:"
CHOICES
( X ) a.) Complete the entire course of antibiotics.
( O ) b.) Avoid contact sports and vigorous exercise for 2 to 4 weeks.
( X ) c.) Remain on bed rest for 4 weeks.
( X ) d.) Not return to school for 4 weeks.
RATIONALE: Splenomegaly often accompanies mononucleosis and is present 2 to 4 weeks after contracting the infection. To prevent splenic rupture, contact sports and vigorous exercise should be avoided. Mononucleosis is caused by the Epstein-Barr virus; antibiotics are not useful unless an accompanying bacterial infection is present. The client should have frequent rest periods, but bed rest is not required for 4 weeks. The client can usually return to school in 1 to 2 weeks or when symptoms and extreme fatigue have improved. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1081 _ about (MC)
QUESTION: "An African American woman is admitted to the hospital after sustaining a hip fracture. She is 5 ft., 4 inches tall and weighs 96 pounds. She has five children and has used estrogen replacement therapies for 10 years. She reports that she "just stepped forward and fell." The results of her bone density tests indicate she has osteoporosis. Which of the following is the greatest risk factor for osteoporosis for this woman?"
CHOICES
( X ) a.) Her race.
( O ) b.) Her weight.
( X ) c.) Her parity.
( X ) d.) Her long-term use of estrogen.
RATIONALE: Heavier body weights and some body fat stress bones and promote their maintenance. Osteoporosis is most often associated with being underweight. Women who are thin throughout their lives are twice as likely to develop hip fractures. Caucasian women are at greater risk than African American women. Child-bearing history is not related to osteoporosis. Estrogen is believed to prevent osteoporosis. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
******************************
--> QUESTION NUMBER _ 1082 _ about (MC)
QUESTION: "The most common causes of megaloblastic, macrocytic anemias are:"
CHOICES
( O ) a.) Folate or vitamin B 12 deficiency.
( X ) b.) Chronic disease.
( X ) c.) Iron deficiency.
( X ) d.) Infection.
RATIONALE: Anemia with characteristics of macrocytic, megaloblastic, normochromic red blood cells is caused by folate or B 12 deficiency. Chronic disease would cause the red blood cells to be microcytic. Iron deficiency would cause the red blood cells to be microcytic. Infection is not a classification of anemia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
******************************
--> QUESTION NUMBER _ 1083 _ about (MC)
QUESTION: "After confirming the diagnosis of iron-deficiency anemia through laboratory values, the next essential test is:"
CHOICES
( O ) a.) Stool guaiac x 3.
( X ) b.) Liver function.
( X ) c.) Lipid profile.
( X ) d.) Endoscopy.
RATIONALE: Stool guaiac would identify blood loss from the gastrointestinal tract, the most common cause of iron-deficiency anemia. Stool guaiac is an easy, inexpensive, noninvasive method of determining if gastrointestinal bleeding is the cause of the anemia. Liver function studies could be done later if blood is detected in the stool. A lipid profile would not give information pertaining to iron-deficiency anemia. Endoscopy could be done later if blood is detected in the stool. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: Prevention and early detection of disease
******************************
--> QUESTION NUMBER _ 1084 _ about (MC)
QUESTION: "The nurse is caring for a client with an exacerbation of ulcerative colitis. Which of the following nursing measures should be included in the client's plan of care?"
CHOICES
( X ) a.) Encourage regular use of antidiarrheal medications.
( O ) b.) Incorporate frequent rest periods into the client's schedule.
( X ) c.) Have the client maintain a high-fiber diet.
( X ) d.) Wear a gown when providing direct client care.
RATIONALE: It is important for the client to have frequent rest periods. Repeated episodes of diarrhea interrupt sleep patterns, and poor nutrition may also cause the client to feel weak. If the client is experiencing a severe exacerbation of ulcerative colitis, bed rest may be ordered. Antidiarrheal medications can be used selectively in ulcerative colitis but are not recommended for regular use as they can lead to colonic dilation. The client should maintain a low-residue, high-calorie, caffeine-free diet. The nurse does not need to wear a gown when providing direct client care because an infectious organism is not present. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
******************************
--> QUESTION NUMBER _ 1085 _ about (MC)
QUESTION: "A 35-year-old female client is diagnosed with aplastic anemia. Which of the following is the most important nursing measure to incorporate into the client's plan of care?"
CHOICES
( X ) a.) Administer prophylactic antibiotics to prevent infection.
( X ) b.) Increase fluids to 3000 mL/day to prevent hemoconcentration.
( O ) c.) Alternate periods of activity with rest to decrease fatigue.
( X ) d.) Encourage the client to prevent respiratory infections by avoiding social situations.
RATIONALE: Activity intolerance is a common problem for clients with aplastic anemia due to decreased hemoglobin. Alternating activity with periods of rest and assisting the client with activities of daily living are appropriate nursing interventions. Antibiotics will not be administered prophylactically. The client should be taught self-care activities to decrease the likelihood of developing an infection. Adequate fluid intake is important but the client does not need to force fluids. Hemoconcentration is not a problem in aplastic anemia. The client should be taught good handwashing techniques and limit contact with individuals who have respiratory illnesses; however, the client does not have to avoid all social situations. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
******************************
--> QUESTION NUMBER _ 1086 _ about (MC)
QUESTION: "Which of the following interventions is most helpful in determining the need for oxygen therapy in a client with chronic obstructive pulmonary disease?"
CHOICES
( X ) a.) Ask the client to tell the nurse when oxygen is needed.
( X ) b.) Assess the client's fatigue level.
( O ) c.) Use a pulse oximeter to determine oxygen saturation.
( X ) d.) Evaluate the client's hemoglobin level daily.
RATIONALE: A pulse oximeter, which measures oxygen saturation, is the most effective noninvasive way to determine a client's need for oxygen therapy. Although the client may feel the need for oxygen during periods of dyspnea, this is not a reliable way of determining the client's need. Fatigue may be due to other factors besides oxygenation levels. Evaluating the client's hemoglobin level can provide an indication that the client may have less oxygen-carrying capacity but is not a reliable indicator of oxygen need. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
******************************
--> QUESTION NUMBER _ 1087 _ about (MC)
QUESTION: "The client with diverticulitis is treated as an outpatient with drug therapy. The nurse would anticipate drug therapy for diverticulitis to include:"
CHOICES
( X ) a.) Antidepressants.
( X ) b.) Laxatives.
( X ) c.) Steroids.
( O ) d.) Broad-spectrum antibiotics.
RATIONALE: Clients with diverticulitis usually receive antibiotics. Anticholinergics may also be prescribed. Antidepressants are not used for treatment of diverticulitis. Laxatives are not used for treatment of diverticulitis as they increase intestinal motility. Bulk laxatives such as Metamucil may be used to provide increased fiber in diet. Steroids are not typically used to treat diverticulitis. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1088 _ about (MC)
QUESTION: "The nurse explains the action of metoclopramide (Reglan) to a client. Which statement best describes the action of Reglan? "
CHOICES
( X ) a.) Reglan decreases gastric acid secretion.
( X ) b.) Reglan neutralizes gastric secretions.
( O ) c.) Reglan stimulates gastric motility.
( X ) d.) Reglan provides a cytoprotective action.
RATIONALE: Metoclopramide (Reglan), which is prescribed to treat gastroesophageal reflux disease, acts by stimulating gastric motility and reducing the volume of gastric reflux. Reglan does not decrease gastric acid secretion, as do histamine H 2-receptor blockers. Reglan does not neutralize the acidity of the secretions as do antacids. Reglan does not provide cytoprotective action to the esophageal mucosa as do some antipeptic agents. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1089 _ about (MC)
QUESTION: "A client takes prednisone for an acute exacerbation of her rheumatoid arthritis. Which of the following statements indicates to the nurse that the client understands how to take the prednisone?"
CHOICES
( X ) a.) "I can stop taking the prednisone as soon as my joints feel better."
( X ) b.) "It is important for me to increase my sodium intake while I am taking this medication."
( X ) c.) "I should not be concerned if I lose a little weight while I take the prednisone."
( O ) d.) "It is best if I take this medication with some food."
RATIONALE: Prednisone is a gastrointestinal irritant that is best taken with food. The client should not abruptly stop taking the prednisone when her joints feel better. Rather, the drug must be tapered slowly. Abrupt withdrawal can precipitate a return of the symptoms. Sodium intake should be reduced, not increased. The client will most likely retain fluids and demonstrate some weight gain. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1090 _ about (MC)
QUESTION: "A client has been placed on isoniazid (INH) as prophylactic treatment against tuberculosis. Which of the following instructions should the nurse plan to include in the client's teaching plan about taking isoniazid?"
CHOICES
( X ) a.) Isoniazid should be taken with antacids to decrease gastric distress.
( O ) b.) The client should limit tyramine-rich foods in his diet.
( X ) c.) Fluid intake should be increased to 3000 mL/day.
( X ) d.) The client can double the dosage if he forgets a drug dose.
RATIONALE: When taking isoniazid, the client should limit tyramine-rich foods in his diet because these foods and the drug could interact to cause hypertension. Foods such as cheese, dairy products, alcohol (red wine and beer), bananas, raisins, caffeine, and chocolate should be limited. Antacids can inhibit the absorption of INH and should not be taken with the drug. The client does not need to increase fluids to 3000 mL/day. The client should not double the dosage if he forgets to take a dose because INH is potentially toxic to the liver. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1091 _ about (MC)
QUESTION: "The nurse is teaching a client about the nutritional modifications he will need to make in his diet because he is taking levodopa for his Parkinson's disease. Which of the following dietary changes will he need to make?"
CHOICES
( X ) a.) Increase amount of potassium in the diet.
( O ) b.) Avoid foods high in pyridoxine (vitamin B 6).
( X ) c.) Increase the amount of protein in the diet.
( X ) d.) Implement a 2-g sodium-restricted diet.
RATIONALE: When taking levodopa, the client should avoid foods and vitamins high in pyridoxine which interferes with the efficacy of the levodopa. The client should also avoid a high protein diet for the same reason. There is no need to increase the amount of potassium in the diet. A high-protein diet will interfere with the efficacy of levodopa. There is no need to implement a sodium-restricted diet. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1092 _ about (MC)
QUESTION: "During an acute attack of Meniere's disease, the nurse can most likely anticipate administering which of the following drugs?"
CHOICES
( X ) a.) Corticosteroids.
( X ) b.) Nonsteroidal anti-inflammatory drugs (NSAIDs).
( O ) c.) Antihistamines.
( X ) d.) Diuretics.
RATIONALE: Antihistamines and anticholinergics are used during an acute attack to suppress the labyrinth. Steroids do not play a role in the treatment of Meniere's disease. NSAIDs do not play a role in the treatment of Meniere's disease. Diuretics are more likely to be used between acute attacks in addition to antihistamines, a low-sodium diet, and elimination of caffeine and nicotine. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1093 _ about (MC)
QUESTION: "Which of the following laboratory tests should be monitored closely by the nurse while the client is receiving heparin therapy? "
CHOICES
( X ) a.) International normalized ratio (INR).
( O ) b.) Activated partial thromboplastin time (APTT).
( X ) c.) Prothrombin time (PT).
( X ) d.) Thrombin time.
RATIONALE: APTT is used to measure the clotting status when the client is receiving heparin. The INR is used to measure clotting status in a client receiving warfarin. Prothrombin time (PT) is used to measure clotting status in a client receiving warfarin. Neither heparin nor warfarin affects thrombin time. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 1094 _ about (MC)
QUESTION: "The client is to receive Lanoxin 0.25 mg. Available are 0.125 mg scored tablets. How many tablets should the nurse administer?"
CHOICES
( X ) a.) 0.5 tablet.
( X ) b.) 1.0 tablet.
( X ) c.) 1.5 tablet.
( O ) d.) 2.0 tablet.
RATIONALE: 0.25 mg/x tablets = 0.125 mg/ 1 tablet x = 2 tablets. 0.25 mg/x tablets = 0.125 mg/ 1 tablet x = 2 tablets. 0.25 mg/x tablets = 0.125 mg/ 1 tablet x = 2 tablets. 0.25 mg/x tablets = 0.125 mg/ 1 tablet x = 2 tablets. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1095 _ about (MC)
QUESTION: "Which of the following nutrients provides a little over half of the energy needed during rest?"
CHOICES
( X ) a.) Protein.
( X ) b.) Carbohydrate.
( O ) c.) Fat.
( X ) d.) Water.
RATIONALE: Nutritional biochemistry and traditional studies of the human body at rest indicate that fat is the primary fuel source. Nutritional biochemistry and traditional studies of the human body at rest indicate that fat is the primary fuel source. Nutritional biochemistry and traditional studies of the human body at rest indicate that fat is the primary fuel source. Nutritional biochemistry and traditional studies of the human body at rest indicate that fat is the primary fuel source. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 1096 _ about (MC)
QUESTION: "The client is to receive 1000 mL of D 5/.25 NS with 15 mEq of KCl over the next 8 hours. The infusion set administers 15 gtt/mL. To what flow rate should the nurse adjust the IV?"
CHOICES
( X ) a.) 21 gtt/min.
( X ) b.) 25 gtt/min.
( O ) c.) 31 gtt/min.
( X ) d.) 35 gtt/min.
RATIONALE: The IV flow rate is determined by the rate of infusion and the number of drops/mL of the fluid being administered. 15 gtts/mL x 1000 mL/480 min = 31 gtts/min. The IV flow rate is determined by the rate of infusion and the number of drops/mL of the fluid being administered. 15 gtts/mL x 1000 mL/480 min = 31 gtts/min. The IV flow rate is determined by the rate of infusion and the number of drops/mL of the fluid being administered. 15 gtts/mL x 1000 mL/480 min = 31 gtts/min. The IV flow rate is determined by the rate of infusion and the number of drops/mL of the fluid being administered. 15 gtts/mL x 1000 mL/480 min = 31 gtts/min. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1097 _ about (MC)
QUESTION: "The nurse is irrigating a client's colostomy when she complains of abdominal cramping after receiving about 100 mL of the irrigating solution. What should the nurse's first response be in this situation?"
CHOICES
( O ) a.) Stop the flow of solution temporarily.
( X ) b.) Reposition the client on to her right side.
( X ) c.) Remove the irrigation tube.
( X ) d.) Massage the abdomen gently.
RATIONALE: The abdominal cramping that can occur during colostomy irrigation results from stimulation of the colon by the irrigating solution. The nurse's first response should be to temporarily stop the flow of solution to allow the cramping to subside. Repositioning the client to the right side will not alleviate the cramping. Removing the tube will not decrease the cramping and will necessitate reinsertion of the tube when the irrigation is resumed. Massaging the abdomen gently may be soothing to some clients, but it is not the nurse's first priority action. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 1098 _ about (MC)
QUESTION: "Which of the following is the single most reliable indicator of the existence and intensity of acute pain?"
CHOICES
( X ) a.) Client's vital signs.
( O ) b.) Client's self-report of pain.
( X ) c.) Nurse's assessment of the client.
( X ) d.) Severity of the condition causing the pain.
RATIONALE: The client's self-report of pain is the single most reliable indicator of the amount of pain the client is experiencing. Pain tolerance and the expression of pain can vary a great deal among clients. The nurse can not determine the intensity of pain by measuring the client's blood pressure, pulse, or respiratory rate. It is essential that the nurse listen to the client. The nurse can not rely on the nurse's own assessment to determine the extent of the pain. The severity of the client's condition does not determine the client's pain response. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1099 _ about (MC)
QUESTION: "The nurse enters the room of a client who has just returned from the operating room after undergoing an incisional cholecystectomy. Which of the following assessment findings would require prompt action by the nurse?"
CHOICES
( X ) a.) The client's abdominal dressing has a 2 x 2-inch area of serous-sanguineous drainage.
( X ) b.) The client's IV solution is infusing at 100 mL/hour and has 75 mL of fluid remaining.
( O ) c.) The client's knee gatch is elevated on the bed.
( X ) d.) The client's Foley catheter is taped to her inner thigh.
RATIONALE: A postoperative client's knees should not have pressure applied behind them, either by the bed's knee gatch or pillows. Such pressure can affect the circulation in the lower extremities, promoting the development of thrombophlebitis. A small amount of serous-sanguineous drainage is normal. The IV bottle will need to be changed within the hour, but the nurse has time to attend to the priority of lowering the knee gatch on the bed. The Foley catheter is taped correctly for the female client. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care
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--> QUESTION NUMBER _ 1100 _ about (MC)
QUESTION: "The nurse is assessing a client's abdominal incision 48 hours after surgery. Which of the following clinical manifestations would most likely indicate that the wound is inflamed?"
CHOICES
( X ) a.) Serous-sanguineous drainage is noted from the wound drain.
( X ) b.) A moderate amount of dried bloody drainage is present on dressing.
( O ) c.) The nurse feels localized warmth over the incisional area.
( X ) d.) The skin is slightly pink around the wound staples.
RATIONALE: Localized warmth over the incisional area indicates that inflammation is present and could indicate the presence of an infection. Serous-sanguineous drainage from a wound drain is normal in the early postoperative phase. Dried bloody drainage is also considered to be a normal finding. A slight pink skin color around staples or sutures is to be expected as the skin is irritated by the presence of the materials. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1101 _ about (MC)
QUESTION: "A client's laboratory tests indicate that the client has hypercalcemia. Which of the following symptoms should the nurse look for in the client?"
CHOICES
( X ) a.) Flushed skin.
( O ) b.) Depressed reflexes.
( X ) c.) Tingling in extremities.
( X ) d.) Diarrhea.
RATIONALE: Calcium aids in nerve impulse transmission, muscle contractions, cardiac contraction, and development of bone and teeth. Clinical manifestations of hypercalcemia include lethargy, weakness, depressed reflexes, constipation, polyuria, and bone pain. Flushed skin is a symptom of hypernatremia. Tingling in the extremities is indicative of hypocalcemia. Constipation, not diarrhea, is seen with hypercalcemia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1102 _ about (MC)
QUESTION: "The client with an abdominal perineal resection and colostomy had a nasogastric tube inserted during surgery. The nasogastric tube will most likely be removed when the client demonstrates which of the following?"
CHOICES
( X ) a.) A decrease in nausea and vomiting.
( X ) b.) A flat, soft abdomen upon palpation.
( O ) c.) Passage of flatus from the colostomy.
( X ) d.) Less than 200 mL gastric drainage in 24 hours.
RATIONALE: A sign indicating that a client's colostomy is ready to function is the passage of flatus. The nurse will auscultate for the presence of bowel sounds. When this occurs, gastric suction is discontinued and the client is started on fluids and food orally. A decrease in nausea and vomiting is not a criterion for determining whether or not the gastric suction should be discontinued. A soft, flat abdomen is an indication that abdominal distention has not developed. It is not an indicator for removal of the nasogastric tube. Gastic drainage is not a criterion for determining whether or not the gastric suction should be discontinued. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 1103 _ about (MC)
QUESTION: "The nurse teaches the client with hepatitis A about how to promote recovery from the disease. Which of the following statements indicates that the client has understood the teaching?"
CHOICES
( X ) a.) "It is okay for me to take medication to help control any abdominal pain."
( O ) b.) "I should find some activities that will keep me occupied as I recover from my fatigue."
( X ) c.) "It will be important for me to limit what I drink so that I don't retain fluids."
( X ) d.) "I will have to limit my protein intake so that I don't stress my liver."
RATIONALE: Recovery from hepatitis can take weeks to months. Clients may become depressed and bored from the fatigue that plagues them and the resulting decrease in activity. The nurse should help the client explore appropriate activities that will help the client cope with the fatigue and decreased activity during recovery. It is not expected that the client will experience any abdominal pain. Fluids are encouraged, not restricted. There is no need for the client to restrict protein. Because anorexia is frequently a problem, the client should be encouraged to eat whatever is nutritious and appetizing. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1104 _ about (MC)
QUESTION: "Which of the following expected outcomes would be appropriate for the client who has ulcerative colitis? "
CHOICES
( X ) a.) The client maintains a daily record of intake and output.
( O ) b.) The client verbalizes the importance of small, frequent feedings.
( X ) c.) The client uses a heating pad to decrease abdominal cramping.
( X ) d.) The client accepts that a colostomy is inevitable at some time in his life.
RATIONALE: Small, frequent feedings are better tolerated by clients with ulcerative colitis as they lessen the amount of fecal material present in the gastrointestinal tract and decrease stimulation. The client does not need to maintain a daily record of intake and output unless an exacerbation of the disease occurs. A heating pad should not be applied to the intestine as it is inflamed. It is not inevitable that the client will require surgery to treat the ulcerative colitis as about 85% respond favorably to conservative therapy. If the severity of the disease mandates surgery, the colon will be removed, resulting in an ileostomy. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 1105 _ about (MC)
QUESTION: "A client with iron-deficiency anemia is prescribed liquid iron supplements. The nurse evaluates the client's understanding of how to take this drug. Which of the following statements indicates the client has adequate knowledge?"
CHOICES
( X ) a.) "I can use antidiarrheal drugs if I develop diarrhea."
( X ) b.) "I will report any black stools to the physician."
( X ) c.) "I will check my gums for any bleeding."
( O ) d.) "I will dilute the medication and drink it with a straw."
RATIONALE: Liquid iron supplements should be diluted and taken through a straw to help decrease the likelihood of staining the teeth. Iron causes constipation, not diarrhea. It is normal for the client's stools to become dark during iron therapy. Iron does not cause bleeding gums. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1106 _ about (MC)
QUESTION: "The nurse is to administer 1 1/2 ounces of Mylanta to a client who has a peptic ulcer. How many mL should the nurse prepare?"
CHOICES
( X ) a.) 15 mL.
( X ) b.) 30 mL.
( O ) c.) 45 mL.
( X ) d.) 60 mL.
RATIONALE: Convert ounces to milliliters. 1 ounce = 30 mL 1 ounce/30 mL = 1.5 ounces/x mL. x = 45 mL. Convert ounces to milliliters. 1 ounce = 30 mL 1 ounce/30 mL = 1.5 ounces/x mL. x = 45 mL. Convert ounces to milliliters. 1 ounce = 30 mL 1 ounce/30 mL = 1.5 ounces/x mL. x = 45 mL. Convert ounces to milliliters. 1 ounce = 30 mL 1 ounce/30 mL = 1.5 ounces/x mL. x = 45 mL. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1107 _ about (MC)
QUESTION: "The nurse needs to instruct an unlicensed assistant on how to collect a urine specimen from an indwelling catheter. Which of the following statements indicates that the assistant understands the instructions?"
CHOICES
( X ) a.) "I should collect urine from the catheter drainage bag at the end of the shift and place it in the specimen container."
( X ) b.) "I will disconnect the drainage tube from the catheter and let urine run from the catheter into the specimen container."
( X ) c.) "I will empty the catheter drainage bag, have the client drink some water, and an hour later collect the urine that drains into the bag."
( O ) d.) "I will get a sterile syringe and remove urine from the catheter through the collection port to place in the specimen container."
RATIONALE: When obtaining a urine specimen from an indwelling catheter, a sterile syringe and needle should be used to access the catheter port that allows removal of urine from the closed system. This technique preserves sterility of the system and the urine specimen. Urine cannot be collected from the drainage bag because it would not be a fresh specimen. Disconnecting the tube from the catheter cab could introduce organisms into the urinary system causing a urinary tract infection. Urine cannot be collected from the drainage bag because it would not be a fresh specimen. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 1108 _ about (MC)
QUESTION: "Lomotil has been prescribed to treat a client's diarrhea. The nurse should teach the client to report which of the following common side effects?"
CHOICES
( O ) a.) Urinary retention.
( X ) b.) Diaphoresis.
( X ) c.) Hypotension.
( X ) d.) Lethargy.
RATIONALE: Lomotil, a combination drug containing atropine, has anticholinergic properties. Common side effects include urinary retention, blurred vision, constipation, palpitations, nervousness, and decreased sweating. This is not a common side effect of Lomotil. This is not a common side effect of Lomotil. This is not a common side effect of Lomotil. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1109 _ about (MC)
QUESTION: "Sulfamethoxazole has been prescribed to treat a client's urinary tract infection. The initial dosage is 2 g orally. The nurse has 500-mg tablets available. How many tablets should the nurse give?"
CHOICES
( X ) a.) 2 tablets.
( X ) b.) 3 tablets.
( O ) c.) 4 tablets.
( X ) d.) 5 tablets.
RATIONALE: Convert the grams to milligrams. 2 g = 2000 mg. 2000 mg/x tablets = 500 mg/1 tablet x = 4 tablets. Convert the grams to milligrams. 2 g = 2000 mg. 2000 mg/x tablets = 500 mg/1 tablet x = 4 tablets. Convert the grams to milligrams. 2 g = 2000 mg. 2000 mg/x tablets = 500 mg/1 tablet x = 4 tablets. Convert the grams to milligrams. 2 g = 2000 mg. 2000 mg/x tablets = 500 mg/1 tablet x = 4 tablets. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1110 _ about (MC)
QUESTION: "Trimethobenzamide (Tigan) 150 mg IM has been ordered to treat a client's nausea and vomiting. The nurse has an ampule of Tigan labeled 200 mg/mL. How many milliliters should the nurse prepare to give the client?"
CHOICES
( X ) a.) 0.50 mL.
( O ) b.) 0.75 mL.
( X ) c.) 1.0 mL.
( X ) d.) 1.5 mL.
RATIONALE: 150 mg/ x mL = 200 mg/mL x = 0.75 mL. 150 mg/ x mL = 200 mg/mL x = 0.75 mL. 150 mg/ x mL = 200 mg/mL x = 0.75 mL. 150 mg/ x mL = 200 mg/mL x = 0.75 mL. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1111 _ about (MC)
QUESTION: "The nurse reviews application of a nitroglycerin topical ointment with a client. Which of the following statements indicates that the client needs additional clarification of the instructions?"
CHOICES
( X ) a.) "I will use the applicator paper to measure the amount of ointment I should use."
( X ) b.) "It is important that I rotate the application sites to avoid skin irritation."
( X ) c.) "I should remove any remaining old ointment with a tissue before applying a new dose."
( O ) d.) "I will carefully massage the ointment into the skin."
RATIONALE: The client should not rub or massage the ointment into the skin. The ointment should be allowed to absorb slowly. The client should use the applicator paper to measure the amount of ointment to apply. The client should rotate the application sites to avoid skin irritation. The client should remove any remaining ointment with a tissue before applying a new dose. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1112 _ about (MC)
QUESTION: "The nurse is preparing a client's preoperative medication. The order reads atropine 0.6 mg and meperidine hydrochloride 50 mg IM. The dosage of available atropine is 0.8 mg/mL and the dosage of available meperidine is 100 mg/mL. What will be the total volume of medication the nurse will administer?"
CHOICES
( O ) a.) 1.25 mL.
( X ) b.) 1.50 mL.
( X ) c.) 1.75 mL.
( X ) d.) 2.00 mL.
RATIONALE: The atropine dosage is calculated as follows: 0.6 mg/ x mL = 0.8 mg/mL x = 0.75 mL. The meperidine dosage is calculated as follows: 50 mg/x mL = 100 mg/mL x = 0.5 mL. The total volume to be administered is 1.25 mL. The atropine dosage is calculated as follows: 0.6 mg/ x mL = 0.8 mg/mL x = 0.75 mL. The meperidine dosage is calculated as follows: 50 mg/x mL = 100 mg/mL x = 0.5 mL. The total volume to be administered is 1.25 mL. The atropine dosage is calculated as follows: 0.6 mg/ x mL = 0.8 mg/mL x = 0.75 mL. The meperidine dosage is calculated as follows: 50 mg/x mL = 100 mg/mL x = 0.5 mL. The total volume to be administered is 1.25 mL. The atropine dosage is calculated as follows: 0.6 mg/ x mL = 0.8 mg/mL x = 0.75 mL. The meperidine dosage is calculated as follows: 50 mg/x mL = 100 mg/mL x = 0.5 mL. The total volume to be administered is 1.25 mL. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1113 _ about (MC)
QUESTION: "Gentamycin (Garamycin) IV has been ordered to treat a client's infection. The nurse understands that it is important to monitor the client for the development of which of the following side effects?"
CHOICES
( X ) a.) Ascites.
( X ) b.) Confusion.
( O ) c.) Ototoxicity.
( X ) d.) Cardiac dysrhythmias.
RATIONALE: Ototoxicity is a serious side effect of gentamycin. Tinnitus and dizziness are common; irreversible deafness can develop if the onset of ototoxicity is not detected early. Gentamycin is also known to be nephrotoxic and hepatoxic. Ascites is not a common side effect. Confusion is not a common side effect. Dysrhythmias are not a common side effect. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1114 _ about (MC)
QUESTION: "Guaifenesin (Robitussin) 300 mg orally has been ordered as an expectorant for a client with nonproductive cough. The liquid suspension is 200 mg/5 mL. How many milliliters should the nurse give the client?"
CHOICES
( X ) a.) 5 mL.
( O ) b.) 7.5 mL.
( X ) c.) 10 mL.
( X ) d.) 15 mL.
RATIONALE: 300 mg/ x mL = 200 mg/ 5 mL x = 7.5 mL. 300 mg/ x mL = 200 mg/ 5 mL x = 7.5 mL. 300 mg/ x mL = 200 mg/ 5 mL x = 7.5 mL. 300 mg/ x mL = 200 mg/ 5 mL x = 7.5 mL. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1115 _ about (MC)
QUESTION: "Morphine 8 mg IM has been ordered for a client. The ampule label reads 15 mg/mL. How many milliliters will the nurse give?"
CHOICES
( X ) a.) 0.45 mL.
( O ) b.) 0.53 mL.
( X ) c.) 0.66 mL.
( X ) d.) 0.75 mL.
RATIONALE: 8 mg/ x mL = 15 mg/ mL x = 0.53 mL. 8 mg/ x mL = 15 mg/ mL x = 0.53 mL. 8 mg/ x mL = 15 mg/ mL x = 0.53 mL. 8 mg/ x mL = 15 mg/ mL x = 0.53 mL. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 1116 _ about (MC)
QUESTION: "A client has been hospitalized with skeletal traction to stabilize a fractured femur. He tells the nurse that he has not had a bowel movement for 2 days. Which of the following interventions would be the most appropriate nursing action?"
CHOICES
( O ) a.) Increase the client's fluid intake to 3000 mL per day.
( X ) b.) Administer an oil retention enema.
( X ) c.) Place him on the bedpan every 3 to 4 hours.
( X ) d.) Perform passive range of motion to extremities.
RATIONALE: The most appropriate nursing action is to first increase the client's fluid intake to 3000 mL per day to soften stool. A stool softener would be prescribed before resorting to an enema. Oil retention enemas are used to soften and lubricate impacted stool. Placing the client on the bedpan every 3 to 4 hours is not enough stimulate a bowel movement. While activity can stimulate peristalsis, passive range of motion is not likely to provide enough stimulation to the abdominal muscles to stimulate a bowel movement. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 1117 _ about (MC)
QUESTION: "The nurse is assessing a client who has been admitted to the emergency department. The client is restless and agitated, has dry mucous membranes, and is complaining of intense thirst. The nurse suspects which of the following electrolyte imbalances?"
CHOICES
( X ) a.) Hypokalemia.
( X ) b.) Hypercalcemia.
( X ) c.) Hypomagnesemia.
( O ) d.) Hypernatremia.
RATIONALE: Restlessness, agitation, dry mucous membranes, and thirst are indicative of fluid loss and hypernatremia. Hypokalemia causes such symptoms as fatigue, muscle weakness, and cardiac irregularities. Clinical manifestations of hypercalcemia include lethargy, weakness, depressed reflexes, constipation, polyuria, and bone pain. Hypomagnesemia is manifested by confusion, tremors, hyperactive reflexes, and seizures. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1118 _ about (MC)
QUESTION: "Which of the following would be an appropriate expected outcome for the client who is 4 weeks status post an abdominal perineal resection with a colostomy? "
CHOICES
( X ) a.) The client will demonstrate an understanding of the need to maintain a high-protein, high-carbohydrate diet.
( O ) b.) The client will verbalize that he feels free to discuss any concerns about his sexuality.
( X ) c.) The client will express an understanding about the need to keep the stoma clean and dry.
( X ) d.) The client will indicate that he needs to irrigate the colostomy every 3 days.
RATIONALE: The client should be encouraged to discuss any concerns about his sexuality. The client will not need to maintain a high-carbohydrate or high-protein diet. Rather, the client will be encouraged to maintain a normal diet while avoiding any foods that cause odor and flatulence. The stoma does not need to be kept clean and dry; rather the skin surrounding the stoma needs to be kept clean and dry. Not every client irrigates his/her colostomy. For those who do, irrigation schedules vary according to the individual. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 1119 _ about (MC)
QUESTION: "A client was recently diagnosed with a deep vein thrombosis in her right leg. The nurse should instruct the unlicensed assistant to incorporate which of the following activities into the client's plan of care?"
CHOICES
( X ) a.) Encourage the client to ambulate twice a shift.
( X ) b.) Have the client do active leg exercises hourly with both legs.
( O ) c.) Keep the right leg elevated above heart level.
( X ) d.) Assess the edema of the right leg every 4 hours.
RATIONALE: The extremity should be kept elevated with heat applied to treat the inflammation and pain. To decrease chances of dislodging a thrombus, the client is typically kept on bed rest during the initial stages of treatment until therapeutic levels of anticoagulation are achieved. The client may exercise the unaffected leg but not the one with the deep vein thrombosis. Assessing the edema of the right leg is an essential activity, but it is the responsibility of the nurse to perform this task. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care
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--> QUESTION NUMBER _ 1120 _ about (MC)
QUESTION: "The nurse is caring for a client who has a history of aplastic anemia. Which of the following data from the nursing history indicates that the anemia is not being managed effectively?"
CHOICES
( O ) a.) Pallor of skin and mucous membranes.
( X ) b.) Heart rate of 68 bpm, bounding pulse.
( X ) c.) Blood pressure of 146/90 mm Hg.
( X ) d.) Poor skin turgor.
RATIONALE: A common clinical manifestation of severe anemia includes pallor of skin and mucous membranes. Other clinical indicators include fatigue, tachycardia, tachypnea, and dyspnea as well as anorexia, sensitivity to cold, and weight loss. This is not a common clinical manifestation of anemia. This is not a common clinical manifestation of anemia. This is not a common clinical manifestation of anemia. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 1121 _ about (MC)
QUESTION: "The nurse is evaluating a client's lung sounds. Which of the following breath sounds indicate adequate ventilation when auscultated over the lung fields?"
CHOICES
( O ) a.) Vesicular.
( X ) b.) Bronchial.
( X ) c.) Bronchovesicular.
( X ) d.) Adventitious.
RATIONALE: Vesicular breath sounds are normal breath sounds heard over all lung fields except the main bronchi. Bronchial breath sounds are heard over the trachea. Bronchovesicular breath sounds can be auscultated over the main bronchi. Adventitious breath sounds are abnormal. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1122 _ about (MC)
QUESTION: "The nurse has an order to administer chlorpromazine (Thorazine) 15 mg IM. The available dosage is 25 mg/mL. How many milliliters should the nurse prepare to administer?"
CHOICES
( X ) a.) 0.5 mL.
( O ) b.) 0.6 mL.
( X ) c.) 0.7 mL.
( X ) d.) 0.8 mL.
RATIONALE: 15 mg/x mL = 25mg/mL x = 0.6 mL. 15 mg/x mL = 25mg/mL x = 0.6 mL. 15 mg/x mL = 25mg/mL x = 0.6 mL. 15 mg/x mL = 25mg/mL x = 0.6 mL. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1123 _ about (MC)
QUESTION: "Which of the following findings in a client's history would be most likely to predispose her to renal calculi?"
CHOICES
( X ) a.) The client had a urinary tract infection within the last 6 months.
( X ) b.) The client takes large doses of vitamin E.
( X ) c.) The client eats a diet that meets the daily requirements for calcium.
( O ) d.) The client drinks one to two glasses of fluid daily.
RATIONALE: Low fluid intake can predispose an individual to stone formation due to the increased urine concentration. Other causes include repeated urinary tract infections, high doses of vitamin C or D, immobility, and large doses of calcium. A single episode of urinary tract infection is not as likely to lead to calculi formation as a routinely low fluid intake. Large doses of vitamin E do not cause renal calculi. A diet that contains the normal daily requirements of calcium will not be as likely to predispose most individuals to renal calculi as a decreased fluid intake. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 1124 _ about (MC)
QUESTION: "A client with a long history of ulcerative colitis takes sulfasalazine (Azulfidine) to control the condition. During the nursing history, the nurse knows to evaluate the client for which nutritional deficit that can occur as a result of taking this drug?"
CHOICES
( X ) a.) Colbalamin.
( O ) b.) Folic acid.
( X ) c.) Niacin.
( X ) d.) Iron.
RATIONALE: Clients who take sulfasalazine are susceptible to developing impaired folic acid absorption. Common clinical manifestations of a folic acid deficiency are gastrointestinal disturbances such as anorexia, nausea, vomiting, and a smooth, beefy red tongue. The client should be encouraged to eat food high in folic acid such as green leafy vegetables, meat, fish, legumes, and whole grains. Colbalamin deficiency is not a side effect of sulfasalazine. Niacin deficiency is not a side effect of sulfasalazine. Iron deficiency is not a side effect of sulfasalazine. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1125 _ about (MC)
QUESTION: "A client diagnosed with tuberculosis is taking the prescribed chemotherapy of isoniazid, rifampin, and pyrazinamide. The nurse should evaluate the client for signs of which of the following commonly occurring toxicities?"
CHOICES
( X ) a.) Ototoxicity.
( X ) b.) Nephrotoxicity.
( X ) c.) Optic neuritis.
( O ) d.) Hepatotoxicity.
RATIONALE: The major side effect of these three drugs is hepatitis. While the client is undergoing chemotherapy for TB, the nurse should carefully monitor the client's liver function tests. Ototoxicity and nephrotoxicity are side effects of other drugs used to treat TB such as streptomycin, kanamycin, and capreomycin. Ototoxicity and nephrotoxicity are side effects of other drugs used to treat TB such as streptomycin, kanamycin, and capreomycin. Optic neuritis can be a side effect of isoniazid. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1126 _ about (MC)
QUESTION: "A client with multiple sclerosis has been prescribed baclofen. The client asks the nurse about the action of the drug. Which of the following is an accurate response regarding this drug's action?"
CHOICES
( X ) a.) "It is an antibiotic that will help treat your urinary tract infection."
( X ) b.) "Baclofen will decrease your fatigue and help increase your energy levels."
( X ) c.) "Taking this drug will help decrease the visual problems you have been having."
( O ) d.) "Baclofen will help relieve the muscle spasms that you have been experiencing."
RATIONALE: Baclofen is a central-acting skeletal muscle relaxant that is used to decrease the spasticity experienced by individuals with multiple sclerosis. Baclofen is not an antibiotic. Baclofen does not decrease fatigue. Common side effects are fatigue and weakness. Baclofen does not improve vision. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1127 _ about (MC)
QUESTION: "Hydromorphone (Dilaudid) 3 mg IV has been ordered for a client who is experiencing severe pain. The dosage available is 3 mg/mL. The nurse dilutes the Dilaudid in 5 mL of normal saline and prepares to administer the medication via IV push over 5 minutes. How many milliliters will the nurse need to administer per minute to administer the drug over 5 minutes?"
CHOICES
( X ) a.) 1.0 mL/min.
( O ) b.) 1.2 mL/min.
( X ) c.) 1.5 mL/min.
( X ) d.) 2.0 mL/min.
RATIONALE: The nurse would need to administer 1.2 mL/min to give the Dilaudid over 5 minutes. When the 3 mg of Dilaudid is diluted with the 5 mL of normal saline, a total of 6 mL of solution results. 6 mL/5 min = 1.2 mL/min. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1128 _ about (MC)
QUESTION: "A client with a seizure disorder has been prescribed phenytoin (Dilantin). Which of the following facts should the nurse include in the teaching plan?"
CHOICES
( X ) a.) The use of phenytoin can lead to the development of diabetes.
( X ) b.) It is appropriate to substitute various brands of phenytoin as long as the dosage is the same.
( X ) c.) It will be necessary for the client to take potassium supplements to prevent hypokalemia.
( O ) d.) The client should use a soft toothbrush and floss teeth daily.
RATIONALE: With long-term use, Phenytoin can cause gingival hyperplasia, so it is essential that the client understand how to provide proper oral hygiene. Phenytoin does not lead to the development of diabetes, but it can affect the diabetics' blood glucose levels and require adjustment of their hypoglycemic agents. The client cannot substitute various brands of phenytoin because they are not bioequivalent. It is not necessary for the client to take potassium supplements. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1129 _ about (MC)
QUESTION: "Pancrelipase (Viokase), an enzyme replacement, has been prescribed for a client with chronic pancreatitis. Which of the following points should the nurse include in the client's teaching plan about the drug?"
CHOICES
( X ) a.) The enzyme mixture should be taken after each meal.
( O ) b.) The client should be careful not to inhale the powder when mixing it with food.
( X ) c.) The enzyme mixture should be stored in the refrigerator to keep it fresh.
( X ) d.) If taking the capsule, the client should chew it thoroughly.
RATIONALE: When mixing the enzyme (lipase, protease, amylase) powder into food, the client should be careful not to inhale it as the powder may trigger an asthma attack. The enzymes are taken before or with each meal, not after. The drug does not need to be stored in the refrigerator. The client should not chew the capsules. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1130 _ about (MC)
QUESTION: "Keflex 0.5 gm has been ordered for a client. The tablets are available in 500 mg doses. How many tablets should the nurse give?"
CHOICES
( X ) a.) 0.5 tablet.
( O ) b.) 1.0 tablet.
( X ) c.) 1.5 tablets.
( X ) d.) 2.0 tablets.
RATIONALE: Convert grams to milligrams. 0.5 g = 500 mg 500 mg/ x tablet = 500 mg/1 tablet x = 1 tablet. Convert grams to milligrams. 0.5 g = 500 mg 500 mg/ x tablet = 500 mg/1 tablet x = 1 tablet. Convert grams to milligrams. 0.5 g = 500 mg 500 mg/ x tablet = 500 mg/1 tablet x = 1 tablet. Convert grams to milligrams. 0.5 g = 500 mg 500 mg/ x tablet = 500 mg/1 tablet x = 1 tablet. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1131 _ about (CM)
QUESTION: "Which questions would be most helpful to ask when completing the initial assessment of a newly admitted client who is complaining of shortness of breath with a diagnosis of heart failure? Select all that apply."
CHOICES
( O ) a.) When did you first notice feeling short of breath?
( O ) b.) Do you have a cough?
( X ) c.) How much caffeine have you had today?
( X ) d.) How long have you been experiencing angina?
( O ) number="5">Do you ever wake up during the night feeling short of breath?
( O ) number="6">How many pillows are you sleeping on?
RATIONALE: Because the client is complaining of shortness of breath with a diagnosis of heart failure, the nurse should anticipate fluid overload. The heart muscle is not adequately pumping, causing a decrease in the stroke volume and increasing the systemic vascular resistance. Obtaining information about when the client first noticed the shortness of breath provides clues to the onset of the fluid build up. Questioning about a cough provides information about fluid accumulation in the lungs. Asking if the client wakes up at night feeling short of breath and about the number of pillows used provides information about the degree and severity of the fluid accumulation in the lungs. The client is not experiencing chest pain, so the question about angina is inappropriate. Although asking about caffeine intake may be helpful for clues related to dietary habits and may be a contributing factor to irregularities in heart rhythm such as palpitations, it would not be helpful when assessing the client's shortness of breath. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1132 _ about (HS)
QUESTION: "A client returns from left aorto-femoral bypass surgery. Identify the area on the illustration where the nurse would place the Doppler ultrasound to assess the left dorsalis pedis pulse."
RATIONALE: The pulse is located on the anterior aspect of the left foot. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1133 _ about (CM)
QUESTION: "The nurse is assigned to a client with peripheral vascular disease. The nursing diagnosis used is alteration in tissue perfusion related to compromised circulation. The nurse would assess the client for which of the following? Select all that apply."
CHOICES
( O ) a.) Nail bed color
( X ) b.) Fluid intake
( O ) c.) Skin temperature
( X ) d.) Nausea
( O ) number="5">Pain in extremity
RATIONALE: Maintaining circulation is critical in individuals with peripheral vascular disease. Skin and nail bed color and temperature will reveal the degree to which the extremity is receiving blood flow. Clients with peripheral vascular disease also usually have a certain amount of pain especially when the oxygen demand becomes greater than oxygen supply, such as with walking or exercising. Fluid intake and complaints of nausea are unrelated to peripheral circulation.
NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 134 _ about (HS)
QUESTION: "A 55-year-old male client arrives at the emergency department with complaints of intermittent chest heaviness and left jaw pain. The nurse performs a 12-lead electrocardiogram (ECG). Identify the area where lead V1 is placed. "
RATIONALE: V1 can be found to the right of the sternum in the fourth intercostal space. Correct placement of lead V1 is important to determine the electrical potential of the heart. Changes in V1 can demonstrate damage to the anterior aspect of the heart. (I, 7) NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 1135 _ about (FI)
QUESTION: "The client is to receive theophylline 500 mg IV in 500 mL of normal saline to run over 4 hours. The tubing delivers 60 gtt/mL. The nurse would set the infusion pump to administer the solution at how many milliliters per hour? "
RATIONALE: To administer intravenous fluids at 500 mL over 4 hours, the nurse must determine the number of milliliters to administer in 1 hour. To do so, divide 500 by 4 to arrive at 125 mL per hour. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1136 _ about (CM)
QUESTION: "The nurse is caring for an elderly client with a suspected diagnosis of pneumonia who has just been admitted to the hospital. The client is slightly confused and is experiencing difficulty breathing. Which activities would be appropriate for the nurse to delegate to the unlicensed assistant? Select all that apply."
CHOICES
( O ) a.) Obtaining vital signs
( X ) b.) Initiating oxygen therapy as needed
( O ) c.) Applying anti-embolic stockings
( X ) d.) Assessing the client's chief complaint
RATIONALE: It is appropriate for the nurse to delegate obtaining vital signs and applying anti-embolic stockings to the unlicensed assistant. The registered nurse is responsible for evaluating the quality and character of the client's vital signs, but the assistant may take the vital signs and report readings to the nurse. It is the registered nurse's responsibility to assess the client's need for oxygen therapy and apply as needed in accordance with physician's orders. It is also the registered nurse's responsibility to perform the nursing history and assessment to gather information about the client's chief complaint. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care
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--> QUESTION NUMBER _ 1137 _ about (CM)
QUESTION: "The nurse is preparing a teaching plan for a client with newly diagnosed hypertension. In addition to reducing sodium intake, what other nutrients would the nurse expect to monitor related to reducing hypertension? Select all that apply."
CHOICES
( O ) a.) Calcium
( X ) b.) Vitamin B6
( O ) c.) Potassium
( O ) d.) Vitamin C
( X ) number="5">Iron
RATIONALE: The "Dietary Approaches to Stop Hypertension" (DASH) diet includes recommendations to reduce sodium intake as well as increasing intake of calcium, potassium, vitamin C, and magnesium. Potassium and magnesium have been shown to both prevent and correct hypertension. Vitamin C appears to help normalize blood pressure. Calcium lowers blood pressure in healthy and hypertensive individuals. Vitamin B6 and iron do not have a clear role in regulating blood pressure. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 1138 _ about (CM)
QUESTION: "Which nursing interventions would be most appropriate when caring for a client who has undergone an uncomplicated appendectomy during the first 24 hours? Select all that apply."
CHOICES
( O ) a.) Placing client in a semi-Fowler's position.
( X ) b.) Maintaining clear liquid diet for 48 hours.
( X ) c.) Monitoring temperature every 2 hours.
( O ) d.) Teaching client how to care for incision.
( X ) number="5">Applying an abdominal binder.
RATIONALE: Following an appendectomy, the client should be placed in a semi-Fowler's position to relieve tension on the abdomen and the surgical incision and promote comfort. Because the client will likely be discharged within 24-48 hours of surgery, teaching the client how to care for the wound is a priority. The client does not need to be limited to a clear liquid diet, but may resume diet as desired following surgery. Although monitoring temperature is important, unless the temperature is elevated, it does not need to be assessed every 2 hours; every 4 hours is sufficient. An abdominal binder is typically not necessary following an appendectomy. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 1139 _ about (CM)
QUESTION: "A client who has ulcerative colitis is taking sulfasalazine (Azulfidine) to treat inflammation. Which of the following instructions related to drug therapy would the nurse include in the client's teaching plan? Select all that apply."
CHOICES
( X ) a.) Taking the medication with meals.
( O ) b.) Avoiding exposure to direct sunlight.
( O ) c.) Drinking a full glass of water when taking the medication.
( O ) d.) Reporting any bruising or bleeding.
( X ) number="5">Taking medication with an antacid to decrease GI side effects.
RATIONALE: Sulfasalazine (Azulfidine) is a sulfonamide antibiotic. The nurse should instruct clients who are taking sulfasalazine to take it 1 hour before or 2 hours following a meal for adequate absorption. The medication should also be taken with a full glass of water to help prevent crystalluria and kidney stones. Photosensitivity can develop so the client should avoid exposure to direct sunlight. Blood disorders such as hemolytic anemia and aplastic anemia may develop with prolonged use; clients should be instructed to report any unusual bruising or bleeding tendencies. Antacids can interfere with the absorption of the medication and should not be taken with the drug. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1140 _ about (CM)
QUESTION: "Which of the following would be priority assessment data to gather from a client who has been diagnosed with hepatic cirrhosis? Select all that apply."
CHOICES
( X ) a.) Heart sounds
( O ) b.) Current use of alcohol
( O ) c.) Nutritional status
( O ) d.) Mental status
( X ) number="5">Capillary refill time
Rationale: For the client with hepatic cirrhosis, it would be important to assess the client's current use of alcohol, because alcohol consumption can have a significant impact on liver function and is, in fact, the major cause of cirrhosis. Continued use of alcohol further destroys liver cells and affects liver function. Assessing the client's nutritional status is also important because impaired nutrition develops in many clients due to gastrointestinal problems and the inability of the liver to metabolize nutrients. Mental status can be affected by the accumulation of ammonia in the blood, leading to hepatic coma if left untreated. The assessment of heart sounds and capillary refill time, while important components of a physical examination, are not priority assessments in the patient with cirrhosis. NURSING PROCESS STEPS: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1141 _ about (CM)
QUESTION: "Which information would the nurse expect to include about hypoglycemia when teaching a client newly diagnosed with type 2 diabetes mellitus? Select all that apply. "
CHOICES
( O ) a.) Regular meals and a bedtime snack will decrease the incidence of hypoglycemia
( X ) b.) Hypoglycemia will not occur unless the client is taking insulin
( O ) c.) Symptoms of hypoglycemia can include irritability, hunger, shaking, and sweating
( O ) d.) A carbohydrate food source should be available during strenuous exercise
( O ) number="5">Alcohol consumption can increase the incidence of hypoglycemia
RATIONALE: Regular meals and snacks are encouraged to prevent hypoglycemia. Strenuous exercise and alcohol consumption can increase the likelihood of hypoglycemia. Therefore, monitoring blood glucose and dietary intake are suggested in these situations. Hypoglycemia can occur with oral diabetic agents even when the client is not taking insulin. Symptoms of hypoglycemia vary, but include irritability, hunger, shaking, sweating, confusion, and headache. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Reduction of risk potential
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--> QUESTION NUMBER _ 1142 _ about (CM)
QUESTION: "When caring for a client with acute renal failure, the nurse would assess the client carefully for signs and symptoms of which most likely electrolyte and metabolic imbalances? Select all that apply."
CHOICES
( X ) a.) Metabolic alkalosis
( O ) b.) Hyperkalemia
( X ) c.) Hypercalcemia
( O ) d.) Metabolic acidosis
( O ) number="5">Hypermagnesemia
RATIONALE: Hyperkalemia (elevated serum potassium) is the most life-threatening electrolyte imbalance that can develop as a result of acute renal failure. Additional electrolyte imbalances include a decrease in serum calcium levels (hypocalcemia) and elevated magnesium levels (hypermagnesemia). Acute renal failure also leads to the development of metabolic acidosis. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1143 _ about (FI)
QUESTION: "The nurse is preparing to administer 500 mL of whole blood to a client. The blood is to be infused over 4 hours. The infusion tubing delivers 10 gtt/mL. How many drops of blood per minute must the nurse infuse to complete the infusion in 4 hours?"
RATIONALE: To administer whole blood at 500 mL/4 hours using tubing that has a drip factor of 10 gtt/mL, the nurse should first convert the 4 hours into minutes, and then use the following formula: 500 cc/240 minutes x 10 gtt/mL = 21 gtt/min. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1144 _ about (CM)
QUESTION: "When discussing contraception with a 37-year-old woman during her annual gynecologic examination, which of the following would the nurse identify as contraindications to combined oral contraceptive use? Select all that apply."
CHOICES
( O ) a.) Smoking 1r pack of cigarettes per day
( X ) b.) Mother with a history of lymphoma
( X ) c.) Multiple sexual partners
( O ) d.) Healing of currently casted fractured femur
( O ) number="5">Use of phenytoin (Dilantin) for seizure disorder
( X ) number="6">History of asthma
Rationale: Absolute contraindications to oral contraceptives include prolonged immobilization or surgery to the leg and age > 35 years when a cigarette smoker, especially in those women who smoke more than 20 cigarettes a day. Oral contraceptives also interact with many antiepileptic drugs including phenytoin, causing a reduction in the therapeutic dose and alteration in the seizure threshold. Multiple sexual partners is not a contraindication, and is often a lifestyle situation where pregnancy is undesired. Women with asthma can safely take oral contraceptives. There is no link with maternal or personal history of lymphoma with oral contraceptives. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1145 _ about (CM)
QUESTION: "When assessing a client complaining of leg pain, which descriptors would the lead the nurse to suspect that the client is experiencing bone pain? Select all that apply."
CHOICES
( O ) a.) Throbbing
( X ) b.) Increased with movement
( O ) c.) Sharp
( X ) d.) Aching
Rationale: Bone pain is usually described as a throbbing sensation, whereas muscular pain is usually described as an aching sensation that increases with movement. Sharp pain occurs with bone trauma such as fractures or bone infections. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 1146 _ about (CM)
QUESTION: "When performing a wound irrigation to a client's surgical wound, which of the following would the nurse include? Select all that apply."
CHOICES
( O ) a.) Using a 35-mL syringe and 19-French angiocatheter
( O ) b.) Irrigating with about 8 pounds of pressure per square inch
( O ) c.) Wearing a mask, eye goggles, gown, and gloves
( X ) d.) Always sedating the client before the irrigation procedure
RATIONALE: The correct procedure for wound irrigation includes using a 35-mL syringe and 19-French angiocatheter to provide irrigation of about 8 pounds of pressure per square inch to remove necrotic tissue without tissue damage. Adherence to standard precautions requires the nurse to wear a mask, eye goggles, gown, and gloves to prevent contamination from the irrigation. The irrigation should not necessarily be painful and sedation is not necessarily required. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control
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--> QUESTION NUMBER _ 1147 _ about (FI)
QUESTION: "The physician orders amoxicillin suspension 375 mg four times a day for a client who has difficulty swallowing pills. The label on the amoxicillin suspension reads 500 mg per 5 cc. How many cubic centimeters (cc's) would the nurse give? "
RATIONALE: 500 mg = 5 cc 375 mg x Solving the proportion: 500 x = 5 x 375 x = 1875/500 x = 3.75 cc NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1148 _ about (FI)
QUESTION: "A client is to receive intravenous fluid at a rate of 150 mL/hour. What is the total amount of fluid in liters that the nurse expects the client to receive in 24 hours?"
RATIONALE: The client receives 150 mL/hour. 150 mL x 24 hours = 3600 mL. Convert the milliliters to liters by dividing by 1000. The total volume in liters for 24 hours is 3.6 L. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1149 _ about (FI)
QUESTION: "The physician orders a client with deep vein thrombosis to receive 7500 units of heparin subcutaneously every 12 hours. The vial on hand reads heparin 10,000 units per mL. How many milliliters of heparin would the nurse prepare in the syringe? "
RATIONALE: 10,000 units /1 mL = 7500U/x 10,000x = 7500 x = 7500/10,000 or 0.75 mL NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1150 _ about (HS)
QUESTION: "The nurse is preparing the morning dose of insulin for a client. The client is to receive 30 units of Humulin regular. Identify on the syringe the correct dosage."
RATIONALE: The X indicates 30 units on the syringe. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1151 _ about (CM)
QUESTION: "A 22-year-old female has lactose intolerance. After teaching the client about foods that will help her maintain adequate calcium intake, which of the following client responses identifying foods to eat or drink indicates she understands the teaching plan? Select all that apply."
CHOICES
( O ) a.) Plain yogurt
( O ) b.) Sardines
( X ) c.) Ice cream
( O ) d.) Acidophilus milk
( O ) number="5">Almonds
RATIONALE: 1 cup of plain yogurt contains calcium; yogurt and acidophilus milk contain bacteria that digest lactose; sardines contain calcium and do not have lactose; almonds contain calcium and do not have lactose. Ice cream is the least appropriate because it contains lactose. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 139 _ about (MC)
QUESTION: "Which of the following expected outcomes would the nurse judge as therapeutic and realistic for a female client with major depression and borderline personality disorder who is hospitalized for self-mutilation and threats of suicide?"
CHOICES
( X ) a.) The client will stay in her room when overwhelmed by feelings.
( X ) b.) The client will leave the group to pace when feeling anxious and angry.
( O ) c.) The client will appropriately verbalize anger and sad feelings to the nurse.
( X ) d.) The client asks the nurse for a prescribed medication when feeling out of control.
RATIONALE: The client needs to ventilate and discuss feelings of anger and sadness with the nurse to decrease behaviors of self-harm. Other alternatives such as punching the pillow may be helpful to the client in expressing anger and rage. Staying in her room when feeling overwhelmed is inappropriate because it will not help the client understand herself or her feelings. Additionally, doing so will not foster growth in autonomy and responsibility for self. Leaving the group to pace when anxious and angry is inappropriate because it will not help the client understand herself or her feelings. Additionally, doing so will not foster growth in autonomy and responsibility for self. Asking for prescribed medications when feeling out of control will not help the client to understand herself or her feelings and will not foster growth in autonomy and responsibility for self. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 141 _ about (MC)
QUESTION: "While examining a female client who comes to the emergency department complaining of a fever and a sore throat, the nurse assesses many bruises in various stages of healing. The client states, "This fever made me so confused and clumsy, I fell several times." Suspecting abuse, the nurse interprets this statement as indicating behavior most probably due to which of the following?"
CHOICES
( X ) a.) Gaining pleasure from being abused.
( O ) b.) Fearing she is to blame for her plight.
( X ) c.) Believing her illness will end the abuse.
( X ) d.) Thinking she can handle the problem when feeling better.
RATIONALE: Battered women commonly deny being abused because they are afraid that they are somehow to blame or deserving of their situation. It is a myth that battered women are masochistic and gain pleasure from abuse. Most battered women want to believe that the abuse will stop, especially during the honeymoon phase when the abuser is apologetic. Handling the problem when she is feeling better is an oversimplification of the dynamics of partner abuse and is not what the victim is concerned with or expressing in her statement. The statement in the scenario reflects denial of the abuse. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 157 _ about (MC)
QUESTION: "A client with bulimia binges twice a day. The nurse interprets these binges as most likely involving which of the following for the client?"
CHOICES
( X ) a.) Feelings of euphoria and gratification.
( O ) b.) Feeling out of control and disgusted with self.
( X ) c.) Leaving traces of food around to attract attention.
( X ) d.) Eating increasing amounts of food for substantial weight gain.
RATIONALE: For the client with bulimia, binges involve a loss of control that results in thoughts of self-deprecation. Binges may reduce the feelings of anxiety felt prior to the bingeing behavior. They are not reflective of feelings of euphoria and gratification. Binges are done secretively; the person has no desire to attract attention. Because of the purging, substantial weight gain usually does not occur. However, the client's weight may fluctuate. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 161 _ about (MC)
QUESTION: "A client is admitted to an inpatient psychiatric unit accompanied by his wife, who reports that he has been "on a spending spree; he sent roses to everyone we know. He plays a seductive game with women he meets, telling them that he's next in line for the throne in some country in Europe." The client becomes very active, moves about, and then puts his arm around a female nurse in a show of affection and says to her, "I sure like you a lot, honey. I can do a lot for you in the real world out there." In this situation, which of the following would be the nurse's best response?"
CHOICES
( X ) a.) "Let's go to the snack room to get some popcorn and a soda."
( X ) b.) "I'll have to tell my supervisor if you don't stop this minute."
( X ) c.) "You know you shouldn't do this. It's against the rules."
( O ) d.) "Please stop. I'm very uncomfortable with your display of affection."
RATIONALE: The manic client needs to have limits set on behavior, especially when this behavior is demanding or seductive. The nurse's best response is to tell the client to stop his behavior, then state the intolerance for it. Although it may become appropriate to divert the client's attention (eg, by suggesting getting something to eat and drink), the nurse must first set limits and explain them to the client. Threatening to tell the supervisor does not tell the client that his behavior is unacceptable. Telling a seductive client that it is against the rules for clients and nurses to display affection toward each other does not tell the client that his behavior is unacceptable. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 173 _ about (MC)
QUESTION: "A client in an inpatient psychiatric unit tells the nurse, "I'm going to divorce my no-good husband. I hope he rots in hell. But I miss him so bad. I love him. When's he going to come get me out of here?" The nurse interprets the client's statements as indicative of which of the following?"
CHOICES
( O ) a.) Ambivalence.
( X ) b.) Autistic thinking.
( X ) c.) Associative looseness.
( X ) d.) Auditory hallucinations.
RATIONALE: Ambivalence refers to strong conflicting attitudes or feelings toward an object, person, goal, or situation evidenced in one instance by the client stating she is going to divorce her husband then stating that she misses and loves him. Autistic thinking is preoccupation with self with little concern for external reality. For example, a client's attention cannot be diverted from examining his hands. Associative looseness is characterized by simultaneous expression of unrelated, or only slightly related, ideas or thoughts. For example, a client states, "We went to a basketball game. Where is my father?" Auditory hallucinations involves hearing sounds, words, or voices not heard by others. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 184 _ about (MC)
QUESTION: "On admission, the client with chronic schizophrenia who is admitted for the third time to a state mental institution under a 72-hour involuntary commitment for evaluation tells the nurse, "I didn't do anything wrong. I was just carrying out the orders God gave me to paint an X on the door of all sinners." Several hours after being admitted, the client wants to leave the hospital. In addition to explaining that the staff is concerned about the client's health and safety, which of the following would the nurse tell the client?"
CHOICES
( X ) a.) "It will take about 3 days to complete the evaluation."
( X ) b.) "You must stay at least 2 days but then may be able to leave."
( O ) c.) "The court has mandated that you undergo a 72-hour evaluation."
( X ) d.) "The law requires you to stay here until you are well."
RATIONALE: Clients admitted involuntarily must remain hospitalized for the time allotted for the evaluation. In this case, the time is 72 hours. The 72 hours do not include weekends or holidays. If the treatment team completes the evaluation in less than the allotted time, they may decide to discharge the client or may institute further commitment procedures. Clients cannot sign themselves out of the hospital during this period. Family members also cannot authorize the client's release. The evaluation may or may not take 3 days. If the treatment team completes the evaluation in less than the allotted time, they may decide to discharge the client or may institute further commitment procedures. Telling the client that the stay must be 2 days is less than the time mandated by the court. The involuntary commitment in this case allots 72 hours for the evaluation. Once this time frame has passed and the physician has not initiated or filed papers for commitment, the client may sign himself out of the institution. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 188 _ about (MC)
QUESTION: "Which of the following techniques would be least appropriate for the nurse to implement in crisis intervention?"
CHOICES
( X ) a.) Encouraging the client to ventilate feelings.
( X ) b.) Including the client in finding solutions to the problem.
( X ) c.) Using active and flexible approaches.
( O ) d.) Attacking the client's maladaptive defenses.
RATIONALE: Attacking the client's defenses decreases his ability to maintain self-esteem and ego integrity. Doing so would be the least appropriate action. Rather the nurse should carefully encourage adaptive defenses. Encouraging the client to ventilate feelings increases his awareness of his feelings and reduces tension. So this technique is appropriate in crisis intervention. Including the client in finding solutions to problems helps the client regain his self-worth and communicates confidence and respect. This technique is appropriate in crisis intervention. Using active and flexible approaches helps the nurse use interventions specific to each crisis situation for a healthy crisis resolution. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 189 _ about (MC)
QUESTION: "The nurse answers a call on a telephone hot line from a man who was at the crisis center once in the past when he made a suicide threat. The client says, "Don't try to help me anymore. This is it. I've had enough and I have a gun in front of me now." Then he hangs up the telephone. Which of the following calls would the nurse make first?"
CHOICES
( X ) a.) Client, to make an attempt to calm him.
( O ) b.) Police, to request their intervention.
( X ) c.) Client's wife at work, to suggest she hurry home.
( X ) d.) Neighbor, to request he go to the client's home immediately.
RATIONALE: The nurse's first responsibility when a client threatens suicide is to do whatever can be done most quickly to protect the client from himself. When the nurse is in a crisis center and the client is at home, it is best to call the police to intervene. They will be able to reach the client quickly and are experienced in handling such situations. It is appropriate to err on the side of safety rather than to assume that the client is not serious about a suicide threat. Attempting to call the client first would be a serious error in judgments because the client has a lethal means, a gun, readily available and is in immediate danger of killing himself. Outsiders, such as a neighbor or even the client's wife, may be hurt, especially when the client has a weapon. Outsiders, such as a neighbor or even the client's wife, may be hurt, especially when the client has a weapon. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 202 _ about (MC)
QUESTION: "When caring for a client receiving haloperidol (Haldol), the nurse would assess for which of the following?"
CHOICES
( X ) a.) Hypertensive episodes.
( O ) b.) Extrapyramidal symptoms.
( X ) c.) Hypersalivation.
( X ) d.) Oversedation.
RATIONALE: Haloperidol (Haldol), a major antipsychotic drug, is associated with a high incidence of severe extrapyramidal reactions. Other side effects of haloperidol include blurred vision, dry mouth, urine retention, and skin rash. At therapeutic dosages, haloperidol is associated with a low incidence of sedation and a low incidence of cardiovascular effects such as hypertension. Hypersalivation is a paradoxical effect of clozapine (Clozaril). At therapeutic dosages, haloperidol is associated with a low incidence of sedation. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 209 _ about (MC)
QUESTION: "Which of the following client statements about clozapine (Clozaril) indicates that the client needs additional teaching?"
CHOICES
( O ) a.) "I need to have my blood checked once every several months while I'm taking this drug."
( X ) b.) "I need to sit on the side of the bed for a while when I wake up in the morning."
( X ) c.) "The sleepiness I feel will decrease as my body adjusts to clozapine."
( X ) d.) "I need to call my doctor whenever I notice that I have a fever or sore throat."
RATIONALE: Agranulocytosis is a serious adverse effect of clozapine (Clozaril). Therefore, the client needs to have complete blood cell counts weekly to monitor for this possible serious decline in white blood cell counts. Because dizziness and hypotension may occur with this drug, sitting on the side of the bed before arising is helpful in preventing falls. The drowsiness and sedative effects of the drug typically diminish as the client's body adjusts to the drug. Because of the risk for agranulocytosis and subsequent infection, the client needs to keep a watchful eye on how he or she is feeling and report any problems, such as fever or sore throat, that possibly indicate an underlying infection. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 211 _ about (MC)
QUESTION: "When asked how she cut her finger, a client with a cognitive disorder says, "While cutting flowers in our garden." The client's husband later tells the nurse that they do not have a flower garden. The nurse interprets the client's statement as which of the following?"
CHOICES
( X ) a.) Displacement.
( O ) b.) Confabulation.
( X ) c.) Disorientation.
( X ) d.) Flight of ideas.
RATIONALE: Because the client has a cognitive disorder and no garden, the nurse interprets the client statement as confabulation (ie, making up stories to fill in memory gaps). Displacement is a defense mechanism that refers ideas and feelings to something or someone not responsible for them (eg, a husband comes home and yells at his wife because of a bad day at work). Disorientation refers to a loss of understanding in relation to place, time, or identity. For example, a client in a nursing home thinks that he is in his own home, the year is 1965, and the nurse is his neighbor. Flight of ideas refers to a rapid shift of thoughts from one subject to another before any idea has been finished (eg, "rain go away, grass is green, my coat is gone, the problem is now"). NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 222 _ about (MC)
QUESTION: "When providing a therapeutic milieu for clients, which of the following would be most appropriate?"
CHOICES
( X ) a.) Using psychotropic drugs primarily.
( X ) b.) Fostering dependent client behavior.
( O ) c.) Accepting behavior as meaningful and motivated.
( X ) d.) Meeting one's own needs while helping clients meet their needs.
RATIONALE: The milieu should provide an atmosphere that fosters growth, change, and self-responsibility. Therefore, the nurse needs to accept behavior as meaningful and motivated. Staff interventions should also be flexible, open, and encourage clients to achieve their own potential. Using psychotropic drugs is only one component of therapeutic milieu. Other components include nurse-client interaction, therapeutic groups, recreation, and client-staff treatment meetings. Independent, not dependent, behavior is fostered and supported to promote the client to assume responsibility for self. Meeting one's own needs while helping clients meet their needs is inappropriate for the nurse or the staff in a therapeutic milieu. The nurse focuses on the client's needs without expecting personal needs to be met. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 225 _ about (MC)
QUESTION: "After the nurse has taught the client who is being discharged on lithium (Eskalith) about the drug, which of the following client statements would indicate that the teaching has been successful? "
CHOICES
( X ) a.) "I need to restrict eating any foods that contain salt."
( X ) b.) "If I forget a dose, I can double the dose the next time I take it."
( O ) c.) "I'll call my doctor right away for any vomiting, severe hand tremors, or muscle weakness."
( X ) d.) "I should increase my fluid intake to five to six 8-ounce glasses of water each day."
RATIONALE: A client receiving lithium is at risk for toxicity, evidenced by diarrhea, vomiting, ataxia, tremor, drowsiness, lack of coordination, or muscle weakness. Thus, the client's statement about notifying the doctor about possible signs of lithium toxicity reflects accurate knowledge about the drug and successful teaching. The client needs to maintain a normal salt intake because eliminating salt from the diet can lead to lithium toxicity. When a dose is skipped or missed, doubling the dose at the next scheduled time increases the client's chance for lithium toxicity. Drinking ten to twelve 8-ounce glasses of water per day is recommended for the client receiving lithium to prevent toxicity. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 228 _ about (MC)
QUESTION: "After hearing a client with bulimia talk about her bizarre eating binges of raw pancake batter and bowls of whipped cream, the nurse feels disgusted and feels like telling her to "snap out of it." Which of the following would be the best action for the nurse at this time?"
CHOICES
( X ) a.) Share these feelings with the client, pointing out that the client's behavior alienates people.
( X ) b.) Ask the client to talk more about her eating habits, trying to understand her underlying problem.
( X ) c.) Suggest that another nurse work with the client because this relationship is no longer therapeutic.
( O ) d.) Discuss these feelings with another nurse or colleague in an attempt to help to resolve them.
RATIONALE: The nurse is experiencing a countertransference reaction that can only be resolved by self-reflection and discussion with other professionals. It is inappropriate for the nurse to tell the client about her feelings because doing so might perpetuate the client's low self-esteem. Continuing to struggle with the problem feelings without analyzing the nurse's own reactions is counterproductive. Asking another nurse to work with the client may solve the problem momentarily, but the nurse will most likely encounter similar problems and clients in the future. Additionally, the client may feel rejected by the nurse if someone else takes over. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 234 _ about (MC)
QUESTION: "Which of the following statements about the initial care of a suspected abuse victim, when documented on the chart, would be least helpful for others when caring for the client?"
CHOICES
( X ) a.) "Requests that her bruises not be described to a doctor."
( O ) b.) "Seems fearful to discuss how bruises on her body had been caused."
( X ) c.) "Asks that her husband not be called at work, stating that he is very busy."
( X ) d.) "Refuses a follow-up appointment, stating that a child at home needs her care."
RATIONALE: Information documented on a client's record should be as objective as possible so that other health personnel can verify findings as necessary. Stating that a client seems fearful to discuss what caused the bruises on her body is a subjective statement that expresses the nurse's opinion. Rather than stating an opinion, the nurse should state exactly what the client said. Documenting the client's request about not describing her bruises to a doctor identifies an objective statement on the client's part. Documenting that the client asks that her husband not be called because he is very busy identifies an objective statement on the client's part. Documenting the client's refusal for follow-up with her statement about a child at home needing care identifies an objective statement on the client's part. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 238 _ about (MC)
QUESTION: "In which of the following instances would the nurse anticipate that a client who has been sexually assaulted will have future adjustment problems and the need for additional counseling?"
CHOICES
( X ) a.) When she becomes upset when talking about the rape to anyone.
( X ) b.) When she seeks support from formerly ignored relatives and friends.
( O ) c.) When her parents show shame and suspicion about her part in the rape.
( X ) d.) When her life becomes focused on helping other rape victims like herself.
RATIONALE: The potential for problems in adjusting after a rape will be increased when those around the victim treat her as though she is to blame for the rape, especially when she already may feel some guilt and shame about it. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. A rape victim is likely showing adjustment to her experience when she is upset about her experience, when she seeks out formerly ignored relatives and friends for support, or when she attempts to help other rape victims. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 241 _ about (MC)
QUESTION: "Which of the following would indicate to the nurse that a male client with bipolar disorder, manic phase, is nearing readiness for discharge?"
CHOICES
( X ) a.) Sleeping 4 hours per night.
( O ) b.) Differentiating realistic self-image from grandiosity.
( X ) c.) Suddenly telephoning his wife and asking her for a divorce.
( X ) d.) Demonstrating a labile affect.
RATIONALE: The client is approaching discharge when he is able to differentiate between a realistic self-image and grandiosity. A client with mania typically experiences a high regard for self or inflated self-image, seen as grandiosity. The ability to view one's self realistically demonstrates improvement. The client in a manic state exhibits a decreased need for sleep due to feelings of having boundless energy and increased activity. Sleeping 4 hours per night indicates that the client is still acutely ill. Suddenly asking for a divorce could indicate the client's poor judgment and inability to perceive his situation realistically. A labile affect or affect that quickly changes is typically seen in the manic state. A client may be laughing or joking one minute, suddenly start to cry, then quickly return to euphoria. A labile affect is an indication that the client is acutely ill. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 472 _ about (MC)
QUESTION: "While interacting with the nurse, a 62-year-old client states that he feels tired all the time, has trouble sleeping, and has a problem with thinking. Which of the following would be the nurse's best action?"
CHOICES
( X ) a.) Inform the client about the normal aging process.
( O ) b.) Further assess the client's mental status and health history.
( X ) c.) Refer the client to a senior citizens' support group.
( X ) d.) Advise the client to discontinue daytime napping.
RATIONALE: Fatigue, difficulty thinking, and sleep disturbances can signal depression or other medical problems. The nurse should explore the client's medical and psychosocial history and conduct a mental status examination to gather additional data before making recommendations. These signs and symptoms are not associated with the normal aging process. Referral to a senior citizens' support group may be appropriate later, depending on the client's needs and interests. At this time, the nurse does not have enough information about the client's daily schedule to suggest that napping is a problem. It is more important to first determine the source of his symptoms so that the client can be treated appropriately. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 473 _ about (MC)
QUESTION: "During the nurse's conversation with a depressed client, the client states, "I have no reason to be sad. I have a great job and a wonderful wife and family." Which of the following comments would be best for the nurse to make at this time?"
CHOICES
( X ) a.) "Why do you think you're depressed?"
( X ) b.) "Think about how fortunate you are."
( X ) c.) "You have many positive qualities."
( O ) d.) "Depression can be caused by a chemical imbalance in the brain."
RATIONALE: The biologic theory of depression suggests that an imbalance of the neurotransmitters serotonin, norepinephrine, and possibly dopamine causes endogenous depression (depression coming from within the person). Asking the client challenging questions such as why he is depressed is not therapeutic and may cause feelings of inadequacy and shame over not being able to answer. Telling the client that he is fortunate may make him feel guilty about his emotional state. Giving the client a pep talk by telling him he has many positive qualities blocks the client's emotional expression. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 474 _ about (MC)
QUESTION: "The client is taking sertraline (Zoloft), 50 mg q AM. The nurse includes which of the following in the teaching plan about Zoloft? Select all that apply."
CHOICES
( O ) a.) 1. Zoloft may cause erectile and ejaculatory dysfunction in some men.
( O ) b.) 2. It may be 1 to 2 weeks after starting Zoloft before the client feels better physically.
( O ) c.) 3. Zoloft causes lightheadedness or dizziness when rising.
( X ) d.) 4. Zoloft increases the appetite and causes weight gain.
( X ) number="5">5. Zoloft can cause agranulocytosis.
( X ) number="6">6. Zoloft may cause seizures.
RATIONALE: Zoloft may cause erectile and ejaculatory dysfunction. A decrease in dosage can decrease these symptoms. Physical benefits typically occur in 1 to 2 weeks. Improvement in thinking and mood may take longer. Zoloft can cause postural hypotension. Zoloft may cause anorexia, not weight gain. Agranulocytosis and seizures are associated with clozapine (Clozaril). NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 475 _ about (MC)
QUESTION: "The nurse meets with the client and his wife to discuss depression and the client's medication. Which of the following comments by the wife would indicate that the nurse's teaching about disease process and medications has been effective?"
CHOICES
( X ) a.) "His depression is almost cured."
( X ) b.) "He's intelligent and won't need to depend on a pill much longer."
( O ) c.) "It's important for him to take his medication so that the depression will not return or get worse."
( X ) d.) "It's important to watch for physical dependency on Zoloft."
RATIONALE: Improved balance of neurotransmitters is achieved with medication. Clients with endogenous depression must take antidepressants indefinitely to prevent a return or worsening of depressive symptoms. Depression is a chronic disease characterized by periods of remission; however, it is not cured. Depression is not dependent on the client's intelligence to will the illness away. Zoloft is not physically addictive. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 476 _ about (MC)
QUESTION: "The nurse meets daily with the depressed client. The client stays mostly in his room and speaks only when addressed, answering briefly and abruptly while keeping his eyes on the floor. The nurse focuses on the client's ability to do which of the following?"
CHOICES
( X ) a.) Make decisions.
( X ) b.) Relate to other clients.
( X ) c.) Function independently.
( O ) d.) Express himself verbally.
RATIONALE: When working with a client who is withdrawn and speaks little, answers briefly, and looks at the floor, the nurse should focus on the simplest type of behavior (ie, behavior requiring the least effort for the client). Decision making is a higher-order cognitive function and will be difficult for the client at this time. Relating to others is an important therapeutic goal; however, short-term goals such as appropriate verbal expression must be accomplished first. Functioning independently is a long-term goal. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
******************************
--> QUESTION NUMBER _ 477 _ about (MC)
QUESTION: "Which of the following client behaviors would best indicate to the nurse that the relationship with the client is in the working phase?"
CHOICES
( X ) a.) The client attempts to familiarize himself with the nurse.
( O ) b.) The client makes an effort to describe his problems in detail.
( X ) c.) The client tries to summarize his progress in the relationship.
( X ) d.) The client starts to challenge the boundaries or outer limits of the relationship.
RATIONALE: This nurse-client relationship is most probably in the working phase. The client's effort to describe his problems to the nurse illustrates that the client has gone beyond testing and acquainting himself with a new relationship and is now working on his problems. The relationship is in an orientation phase when the client attempts to familiarize himself with the nurse. The relationship is in a termination phase when the client summarizes and evaluates his progress. The relationship is in the orientation phase when the client challenges boundaries of the relationship. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 478 _ about (MC)
QUESTION: "A client is admitted to the psychiatric unit with complaints of sleep disturbance, fatigue, feelings of uselessness, and inability to concentrate. The client was let go from her place of employment last month owing to her inability to keep up with the demands of her position. On the day after an interview during which the client talked at length and tearfully about feeling useless and old, she failed to keep an appointment with the nurse. Which action would be best for the nurse to take?"
CHOICES
( X ) a.) Assume that the client had a good reason for not coming and let her make the next move.
( X ) b.) Confront the client with her behavior and ask her to explain the reason for her absence.
( O ) c.) Seek out the client at the end of the scheduled interview time and tell her she was missed today.
( X ) d.) Arrange for another session with the client later the same day and say nothing about her absence.
RATIONALE: The responsibility for maintaining a relationship with a client rests with the nurse. If a client misses a scheduled interview, the nurse is assuming responsibility for the relationship by seeking her out at the end of the scheduled interview time and telling her she was missed. Without knowing the facts, the nurse makes an assumption by thinking that the client has good reason for not keeping her appointment. The nurse is not assuming responsibility by waiting for the client to make the next move in this situation. To confront the client with her absence and ask her to explain it is threatening and not therapeutic. To arrange another session with the client and to say nothing about the missed appointment does not keep to the terms of the nurse-client contract and offers little help to the client. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 479 _ about (MC)
QUESTION: "The client has tearfully described her negative feelings about herself to the nurse during their last three interactions. Which of the following goals would be most appropriate for the nurse to include in the care plan at this time? The client will:"
CHOICES
( X ) a.) Increase her self-esteem.
( X ) b.) Write her negative feelings in a daily journal.
( X ) c.) Verbalize her work-related accomplishments.
( O ) d.) Verbalize three things she likes about herself.
RATIONALE: Describing and verbalizing feelings are necessary and normal because the client has usually repressed or blocked feelings that are partly responsible for the client's pain. Expressing feelings is a prerequisite before the nurse can intervene in how the client thinks or behaves. Asking the client to identify only three qualities is not overwhelming. Stating a goal such as increasing self-esteem is too global and nonspecific. Writing feelings in a journal will not benefit the client because she has verbalized them to the nurse. Verbalizing work-related accomplishments is too specific and focuses on only one client aspect. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 480 _ about (MC)
QUESTION: "The client with depression has been hospitalized for 3 days on the psychiatric unit. This is the second hospitalization during the past year. The physician orders a different drug, tranylcypromine sulfate (Parnate), when the client does not respond positively to a tricyclic antidepressant. Which of the following reactions should the client be cautioned about if her diet includes foods containing tyramine?"
CHOICES
( X ) a.) Heart block.
( X ) b.) Grand mal seizure.
( X ) c.) Respiratory arrest.
( O ) d.) Hypertensive crisis.
RATIONALE: Tranylcypromine sulfate (Parnate) is a monoamine oxidase (MAO) inhibitor. A client taking this drug in combination with foods or beverages rich in tyramine can have a hypertensive crisis because tyramine, a precursor to norepinephrine, is usually deactivated in the GI tract. MAO inhibitors block the deactivation of tyramine. It is then absorbed systemically, causing a sudden release of large amounts of norepinephrine. Heart block is not a side effect of tranylcypromine sulfate. Grand mal seizures are not a side effect of tranylcypromine sulfate. Respiratory arrest is not a side effect of tranylcypromine sulfate. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 481 _ about (MC)
QUESTION: "The nurse would teach the client taking tranylcypromine sulfate (Parnate) to avoid which food because of its high tyramine content?"
CHOICES
( X ) a.) Nuts.
( O ) b.) Aged cheeses.
( X ) c.) Grain cereals.
( X ) d.) Skim milk.
RATIONALE: Aged and strong cheeses are tyramine-rich foods. When ingested in combination with monoamine oxidase inhibitors, they can cause a severe hypertensive crisis. Other foods and beverages rich in tyramine include aged meat and other nonfresh meat, liver, dried fish, any fermented high-protein food (eg, yeast extracts and concentrates), Italian broad beans (pods), green bean pods, wine, beer, and ale. Nuts are not high in tyramine. Grain cereals are not high in tyramine. Skim milk is not high in tyramine. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 482 _ about (MC)
QUESTION: "In terminating the relationship with the nurse, which client reaction should be considered the most healthy?"
CHOICES
( X ) a.) A lack of response.
( X ) b.) A display of anger.
( X ) c.) An attempt at humor.
( O ) d.) An expression of grief.
RATIONALE: Grief is a direct and appropriate response to termination of a positive relationship. Grief indicates acceptance of termination. A lack of response may be interpreted as indifference, but it represents a profound emotional reaction that the client is unable to express. Anger is healthy when openly expressed but is a less healthy reaction than grief. Humor may be a defense against feelings of loss. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 483 _ about (MC)
QUESTION: "Which of the following rights does a client lose by being admitted involuntarily to a psychiatric hospital? The right to:"
CHOICES
( X ) a.) Send and receive mail.
( X ) b.) Vote in a national election.
( X ) c.) Make a will or legally binding contract.
( O ) d.) Sign out of the hospital against medical advice.
RATIONALE: A person who has been involuntarily committed to a psychiatric hospital loses the right to leave the hospital of his own accord. The person who is involuntarily committed to a psychiatric hospital does not lose the right to send and receive mail. The person who is involuntarily committed to a psychiatric hospital does not lose the right to vote. The person who is involuntarily committed to a psychiatric hospital does not lose the right to make a will or contract. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care
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--> QUESTION NUMBER _ 484 _ about (MC)
QUESTION: "When a client expresses feelings of unworthiness, how would the nurse best respond?"
CHOICES
( X ) a.) "Your family loves you even if you feel unworthy."
( X ) b.) "Your feelings of being unworthy are just your imagination."
( X ) c.) "It would be best to try to forget the idea that you are unworthy."
( O ) d.) "As you begin to feel better, your feelings of unworthiness will begin to disappear."
RATIONALE: When the client feels unworthiness, she reflects low self-esteem. Presenting another set of facts in a manner that is accepting of the client but avoids a power struggle is helpful. Telling the client that her family still loves her is a type of pep talk that serves to block the client's emotional expression. Telling the client that her feelings are imaginary shows disapproval and may shame the client for having such feelings. Telling the client that she should try to forget ideas of unworthiness disregards her feelings and may be perceived as rejection. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 485 _ about (MC)
QUESTION: "A client with major depression states to the nurse, "My heart is turning to stone." Which reply by the nurse is most therapeutic?"
CHOICES
( X ) a.) "You are alive and breathing."
( X ) b.) "Your depression makes you think that way."
( X ) c.) "What makes you say that?"
( O ) d.) "You sound like you feel frightened."
RATIONALE: The nurse's best response will be to focus on the underlying meanings of the client's remark without focusing on or challenging the content. Telling the client that she is alive and breathing challenges the client and minimizes the underlying feelings. Stating that the depression is causing the client to make those statements will force the client to defend and reinforce those beliefs. Asking the client what makes her say that forces her to defend her statement. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 486 _ about (MC)
QUESTION: "A client is being admitted to the psychiatric unit. She responds to some of the nurse's questions with one-word answers. Her eyes are downcast and her movements are very slow. Later that morning, the nurse approaches the client and asks how she feels about being in the hospital. The client does not respond verbally and continues to gaze at the floor. Which of the following actions should the nurse take first?"
CHOICES
( O ) a.) Spend time sitting in silence with the client.
( X ) b.) Leave the client alone and tell her that you will be back later to talk.
( X ) c.) Introduce another client to her and ask him to join you.
( X ) d.) Ask another staff member to include the client in an informal group discussion.
RATIONALE: Sitting in silence with the client shows that the nurse accepts and cares about her. It also will help the client to get to know the nurse, initiate a feeling of comfort with the nurse, and lead to development of trust. Telling the client that the nurse will be back to talk later will only burden the client with the nurse's expectation to talk, which the client may not be likely to meet. Introducing another client and asking him to join you and the client will overwhelm the client and increase her anxiety. The client needs to first interact with one person, the nurse, before progressing to interactions with others. Including the client in group discussion will increase her discomfort and anxiety and will not be therapeutic at this time. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 487 _ about (MC)
QUESTION: "The nurse observes that a depressed client has bathed, is wearing a clean blouse and slacks, and has combed her hair. Which statement by the nurse would be most helpful for the client?"
CHOICES
( X ) a.) "You look good today."
( X ) b.) "I'm glad you're feeling better today."
( O ) c.) "I'm glad you combed your hair today."
( X ) d.) "I like your blouse and slacks."
RATIONALE: Relating to the client that she combed her hair points out a visible accomplishment and reinforces positive self-care behavior. Telling the client that she looks good today implies that the client did not look good yesterday. Expressing gladness that the client is feeling better today may be an erroneous interpretation. The client may feel just as depressed as before. If the nurse compliments the client's blouse and slacks, the client may infer that the nurse did not like the client's previous clothing. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 488 _ about (MC)
QUESTION: "A client with recurrent, endogenous depression has been hospitalized on the psychiatric unit for 3 days. He exhibits psychomotor retardation, anhedonia, indecision, and suicidal thoughts. Which goal of nursing care should have highest priority?"
CHOICES
( X ) a.) Provide for contact between the client and his wife.
( O ) b.) Use measures to protect the client from harming himself.
( X ) c.) Reassure the client of his worthiness.
( X ) d.) Maintain a calm environment.
RATIONALE: Whenever a client is suicidal, steps must be taken to prevent the client from self-harm. Other goals of care are less important than being sure the client does not carry out the threat of suicide. All suicide threats should be taken seriously, and proper precautions should be taken to protect the client from self-harm. Providing for contact between the client and his wife is not the highest priority, may not be therapeutic, and would require the client's consent. Reassuring the client of his worthiness is not as high a priority as is his safety. Furthermore, reassurance is not helpful because logical explanation will not change the client's negative thinking. Interventions designed to increase the client's self-esteem are important but are not the highest priority. Maintaining a calm environment is helpful but is not a priority. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control
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--> QUESTION NUMBER _ 489 _ about (MC)
QUESTION: "The nursing assistant approaches the nurse and states, "The client doesn't know what caused him to be so depressed. He must not want to tell me because he doesn't trust me yet." In responding to this staff member, which of the following statements by the nurse will help the assistant understand the client's illness?"
CHOICES
( O ) a.) "Endogenous depression is biochemical and isn't caused by an outside stressor or problem. The client can't tell you why he's depressed because he really doesn't know."
( X ) b.) "Endogenous depression can be caused by various stressors. Perhaps the client isn't willing to tell you at this time."
( X ) c.) "Endogenous depression comes from within the person. It's a reaction to a loss. You need to give the client more time to identify the cause or loss."
( X ) d.) "Endogenous depression usually derives from past childhood conflicts. It really isn't important for the client to remember what happened years ago."
RATIONALE: The cause of endogenous depression is believed to be biochemical and not a reaction to a loss. It is caused by an imbalance or decreased availability of norepinephrine, serotonin, and possibly dopamine, so the client cannot identify a specific outside cause or a loss. Reactive depression is a reaction to a loss or a stressor. It is wrong to consider that lack of trust or slow thinking are reasons why the client will not identify the cause of his depression. Problems and stressors from past childhood conflicts may be present; however, he can discuss them with the staff when he is willing or able. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care
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--> QUESTION NUMBER _ 490 _ about (MC)
QUESTION: "A depressed client's condition improves, but he still remains alone in his room most of the time. Which of the following statements by the nurse would most likely help the client become involved with a unit activity?"
CHOICES
( X ) a.) "Would you like to go to the movie with me today?"
( O ) b.) "I'll be back at 4 o'clock to take you to the movie."
( X ) c.) "I hope you go to the movie this afternoon. It will cheer you up."
( X ) d.) "You might want to go to the movie in the dayroom this afternoon."
RATIONALE: A depressed client is often ambivalent; that is, he both wants to and does not want to carry out an activity. This client's disinterest may not really indicate a wish to be left alone. Making an appointment to take a client to a unit activity is more helpful than allowing the client to say he does not wish to go or leaving it up to the client to decide on his own. This client should not be given choices that allow him to say no. This comment is an example of a pep talk that only serves to block expression of emotion. Leaving it up to the client to decide whether or not he wants to go is not helpful. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 491 _ about (MC)
QUESTION: "The physician orders venlafaxine (Effexor) for the client. The nurse explains the purpose of the medication to the client. The client asks the nurse, "If I start taking the pills, I'll have to take them the rest of my life, won't I?" Which would be the nurse's most accurate and therapeutic reply?"
CHOICES
( X ) a.) "Now don't think that way."
( X ) b.) "The medication prescribed is safe and routine."
( O ) c.) "After your symptoms decrease, the need for medication will be reevaluated."
( X ) d.) "I would hope not!"
RATIONALE: This response provides the most complete information about both the current and future treatment plans and answers the question asked by the client. This response dismisses the client's concern and does not answer the question. This response does not answer the question and ignores the client's concern. This response ignores the client's concerns and causes the client anxiety. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 492 _ about (MC)
QUESTION: "Which of the following health status assessments must be completed before the client starts taking imipramine (Tofranil)?"
CHOICES
( O ) a.) Electrocardiogram (ECG).
( X ) b.) Urine sample for protein.
( X ) c.) Thyroid scan.
( X ) d.) Creatinine clearance test.
RATIONALE: Because tricyclic antidepressants such as imipramine (Tofranil) cause tachycardias and ECG changes, an ECG should be done before the client takes the medication. While imipramine can cause urinary retention, proteinuria is not a side effect. Imipramine is administered cautiously to clients receiving thyroid medication but pretreatment thyroid scan is not necessary. Imipramine does not interfere with kidney function. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 493 _ about (MC)
QUESTION: "One nurse strongly believes that all psychiatric medication is a form of chemical mind control. When the client's wife asks about the efficacy of antidepressant medications, which of the following courses of action would be best for this nurse to take?"
CHOICES
( X ) a.) Give an honest opinion of the treatment.
( O ) b.) Refer the client's wife to another knowledgeable person for information about the treatment.
( X ) c.) Explain that there are not enough current statistics about the efficacy of the treatment.
( X ) d.) Provide a package insert for the wife to read.
RATIONALE: When strongly opposed to a type of therapy, the nurse should refer people who ask about the therapy to another knowledgeable person. If the nurse gives the client and family an honest opinion, it may cause the client and family to lose confidence in prescribed therapy. It would be dishonest to tell the client and family that there are not enough statistics to judge efficacy. Just providing a copy of the package insert is impersonal and likely to be of little help. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 494 _ about (MC)
QUESTION: "The nurse visits the client in a group home 1 week after discharge. He is prescribed fluoxetine (Prozac), 40 mg daily at 9 AM. The client states he feels nervous and has had diarrhea. The nurse appraises the client's symptoms to be which of the following?"
CHOICES
( O ) a.) Important, probably suggesting a decrease in dosage or change to another medication.
( X ) b.) Of no consequence because the client's symptoms are side effects of the Prozac.
( X ) c.) Indicative of an exacerbation of the client's depression.
( X ) d.) Unimportant and a method to elicit the nurse's empathy and attention.
RATIONALE: Anxiety and diarrhea are side effects of Prozac and may be relieved by a decrease in dosage. It may be necessary to change to another selective serotonin reuptake inhibitor or to a different class of antidepressants. All complaints of side effects from medication are important to evaluate. The discomfort experienced by the client could lead to medication noncompliance and dehydration. The client's symptoms alone do not indicate a worsening of depression. A worsening of the depression would be characterized by a more depressed mood, inability to experience pleasure, and appetite disturbances. Diarrhea is not a symptom of depression. Concluding that the client's symptoms are a means to seek attention is a grave error of judgment. Other behaviors or evidence would need to be present for the nurse to reach that conclusion. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 495 _ about (MC)
QUESTION: "A client is admitted to the psychiatric unit accompanied by her husband. She brings six suitcases and three shopping bags. She orders the nurse to carry her bags. Her husband states she has been purchasing items that they cannot afford and has not slept for 4 nights. Which additional information would be a priority for the nurse to seek from the client's husband?"
CHOICES
( O ) a.) The client's fluid and food intake.
( X ) b.) Their current financial status.
( X ) c.) The client's usual sleeping pattern.
( X ) d.) Whether or not the client becomes agitated easily.
RATIONALE: Assessing nutritional status is a priority in this situation. Clients with bipolar disorder, manic phase, commonly do not have time to eat or drink because of their state of constant activity and easy distractibility. Altered nutritional status and constant physical activity can lead to malnutrition, weight loss, and physical exhaustion. These states can lead to death if appropriate intervention is not instituted. Financial status is neither important nor something that the nurse can modify. Clients with bipolar disorder, manic phase, have disturbed sleep patterns; however, their hydration and nutritional status are the first priority. A common behavior of clients with bipolar disorder, manic phase, is to exhibit hostility when their personal desires are limited, so it is not necessary to seek this information at this time. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 496 _ about (MC)
QUESTION: "A client with bipolar disorder in a manic phase puts out her hand and says to the nurse, "Watch out! Here I come." She then puts her hand down and sits in a chair. After determining that the client is not going to harm anyone, the nurse should intervene by doing which of the following?"
CHOICES
( X ) a.) Giving the client a book of her choice to read.
( X ) b.) Placing the client in isolation to work out her aggression in private.
( O ) c.) Taking the client to a punching bag for exercise to release excess energy.
( X ) d.) Having the client continue to sit while holding her hands to help her gain control.
RATIONALE: If a client acts aggressively, the nurse must first take measures to protect himself or herself and others from harm. The nurse should then provide activity that will decrease tension and energy, such as suggesting the client use a punching bag. However, when selecting an activity for a hyperactive client, care should be taken so that the activity does not overstimulate an already overactive client. Offering the client a book to read will not help as manic clients often cannot sit still and must be active. Placing her in isolation to work out aggression in private will not meet her needs to reduce energy and tension. Holding the client's hands may be an attempt to physically control the client and may be perceived as threatening. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 497 _ about (MC)
QUESTION: "The nurse notes that a client is too busy investigating the unit and overseeing the activities of other clients to eat dinner. To help the client obtain sufficient nourishment, which of the following plans would be best?"
CHOICES
( O ) a.) Serve foods that she can carry with her.
( X ) b.) Allow her to send out for her favorite foods.
( X ) c.) Serve food in small, attractively arranged portions.
( X ) d.) Allow her to enter the unit kitchen for extra food as necessary.
RATIONALE: Because the client is very active, it would be best to give her food she can carry with her and eat as she moves. Allowing the client to send out for her favorite foods will not address her need to be active. Serving food in small, attractively arranged portions does not address the client's need to be active. Allowing the client in the unit kitchen is impractical, and she most likely would be too busy to eat anyway. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 498 _ about (MC)
QUESTION: "A client with bipolar disorder, manic phase, just sat down to watch television in the lounge. As the nurse approaches the lounge area, the client states, "The sun is shining. Where is my son? I love Lucy. Let's play ball." The client is displaying:"
CHOICES
( X ) a.) Concreteness.
( O ) b.) Flight of ideas.
( X ) c.) Depersonalization.
( X ) d.) Use of neologisms.
RATIONALE: The client is demonstrating flight of ideas, or the rapid, unconnected, and often illogical progression from one topic to another. Concreteness involves interpreting another person's words literally. Depersonalization refers to feelings of strangeness concerning the environment or the self. A neologism is a word coined by a client. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 499 _ about (MC)
QUESTION: "A client is intrusive and disruptive to other clients. He constantly walks about the unit interrupting others. Which plan should the nurse institute first in this situation?"
CHOICES
( X ) a.) Escort the client to his room and explain that he cannot come out until he gets permission.
( O ) b.) Set limits on the client's behavior. Explain what is expected and what the consequences will be if limits are violated.
( X ) c.) Ask another staff member to take the client to watch television for the next hour.
( X ) d.) Bargain with the client. Explain which privileges he can attain if he can control his behavior.
RATIONALE: Setting limits on behavior and explaining consequences if the limits are violated informs the client about unacceptable behaviors and encourages him to take responsibility for his actions. Taking the client to his room and telling him that he can come out when permitted does not teach him acceptable behavior, give him the opportunity to accept responsibility for himself, or clearly define the consequences of the inability to control himself. Asking a staff member to take the client to watch television is not appropriate because, in addition to the above, the client most likely cannot sit for an hour. The television also may be too stimulating. The nurse should never bargain or argue with a client. Rather, the nurse states what the limits are, what is expected, and what will occur if limits are not observed. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 500 _ about (MC)
QUESTION: "A client with bipolar disorder, manic phase, begins to swear at the nurse when reminded to limit his telephone call to 10 minutes. Which statement by the nurse is most effective in this situation?"
CHOICES
( X ) a.) "You need to act like an adult."
( X ) b.) "You know better than to use that language."
( X ) c.) "Others can hear you."
( O ) d.) "Stop! Swearing is not appropriate behavior."
RATIONALE: The nurse sets limits on unacceptable or threatening behavior to help the client regain control and preserve his self-esteem. Saying "You need to act like an adult" is an authoritarian comment that shames the client and diminishes self-esteem. Saying "You know better than that" shames the client and diminishes self-worth. Saying "Others can hear you" is not helpful because it does not point out the unacceptable behavior. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 501 _ about (MC)
QUESTION: "A client has been taking lithium carbonate (Lithobid) for hyperactivity, as prescribed by his physician. While the client is taking this drug, the nurse should ensure that he has an adequate intake of:"
CHOICES
( O ) a.) Sodium.
( X ) b.) Iron.
( X ) c.) Iodine.
( X ) d.) Calcium.
RATIONALE: Sodium is necessary for renal excretion of lithium carbonate (Lithobid). A low sodium intake results in retention of lithium and eventual lithium toxicity. Iron is not necessary for the metabolism of lithium. Iodine is not necessary for the metabolism of lithium. Calcium is not necessary for the metabolism of lithium. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 502 _ about (MC)
QUESTION: "Which of the following clinical manifestations would alert the nurse to lithium toxicity?"
CHOICES
( X ) a.) Increasingly agitated behavior.
( X ) b.) Markedly increased food intake.
( X ) c.) Sudden increase in blood pressure.
( O ) d.) Lethargy and weakness with vomiting.
RATIONALE: Clinical manifestations of lithium toxicity include muscle weakness, lack of coordination, vomiting, diarrhea, coarse hand tremors, twitching, lethargy, polyuria, and mental confusion. Agitation is not a symptom of lithium toxicity. Increased food intake is not a symptom of lithium toxicity. Increased blood pressure is not a symptom of lithium toxicity. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 503 _ about (MC)
QUESTION: "After 10 days of lithium therapy, the client's lithium level is 1.0 mEq/L. The nurse knows that this value indicates which of the following?"
CHOICES
( X ) a.) A laboratory error.
( O ) b.) An anticipated therapeutic blood level of the drug.
( X ) c.) An atypical client response to the drug.
( X ) d.) A toxic level.
RATIONALE: The therapeutic blood level range for lithium is between 0.6 and 1.2 mEq/L for adults. A level of 1.0 mEq/L can be anticipated after 10 days of treatment. While lab error can occur, this level is therapeutic after 10 days of therapy. Questioning lab error is more plausible if the level were extremely high or low. An atypical response would be manifested as an unusual physical or psychological response, not through blood levels. Lithium toxicity occurs at levels above 1.5 mEq/L. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 504 _ about (MC)
QUESTION: "The client expresses the belief that he was born out of wedlock to a famous woman. When dealing with this delusion of grandeur, which of the following should the nurse try first?"
CHOICES
( X ) a.) Get the client to discuss another topic.
( X ) b.) Involve the client in a simple group project.
( X ) c.) Convince the client that he is wrong in his belief.
( O ) d.) Satisfy the client's implied need to feel important.
RATIONALE: When a client has delusions of grandeur, it is helpful to try to satisfy his implied need to feel important because this recognizes the cause of the behavior (feelings of inadequacy) and helps make him feel important. For example, the client could help the nurse with a simple task. It is not helpful to change the topic of discussion, as this will not address his need to feel important. While involving him in a group project may be therapeutic for other reasons, it does not specifically address his need to feel important. Trying to convince him that his thoughts are erroneous is antagonistic, challenges the client's beliefs, and forces the client to cling to his beliefs to preserve self-esteem. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 505 _ about (MC)
QUESTION: "A client is irritable and hostile. He becomes agitated and verbally lashes out when his personal needs are not immediately met by the staff. When the client's request for a pass is refused by the physician, he utters a stream of profanities. Which of the following statements best describes the client's behavior?"
CHOICES
( O ) a.) The client's anger is not intended personally.
( X ) b.) The client's anger is a reliable sign of serious pathology.
( X ) c.) The client's anger is an intended attack on the physician's skills.
( X ) d.) The client's anger is a sign that his condition is improving.
RATIONALE: Staff members sometimes are the recipients of a client's angry behavior because they are safe targets and are available for attack. The display of anger is rarely intended to be personal. Such behavior is not necessarily a sign of serious pathology but must be weighed in conjunction with other behaviors. An angry outburst is not an attack on a physician's skills. While not necessarily pathological, the client's behavior isn't a sign that his condition is improving. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 506 _ about (MC)
QUESTION: "A client with bipolar disorder, manic phase, is yelling at another client. The client's face is flushed and his fists are clenched. Which of the following nursing actions should be taken first?"
CHOICES
( X ) a.) Summon additional help and escort the client to his room.
( X ) b.) Administer intramuscular lorazepam (Ativan).
( O ) c.) Direct the client to his room for a time out.
( X ) d.) Discuss the problem with the client.
RATIONALE: The client is in the escalation phase of the assault cycle. Applying the principle of the least restrictive alternative, such as a time out, is the nurse's first action. Forcibly escorting the client to his room is more restrictive and not indicated at this time because the client has not lost control. Administering intramuscular lorazepam is not indicated because the client has not lost control. The nurse might offer oral lorazepam if the client is having trouble calming down while in time-out. Discussing the problem is not appropriate in the escalation phase but is appropriate in the triggering phase. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 507 _ about (MC)
QUESTION: "A client with bipolar disorder meets with the nurse at the community mental health center for follow-up care. The client has been taking valproic acid (Depakene), 500 mg three times a day for 1 month. The serum blood level is 60 mcg/mL. The client states that her stomach feels upset after she takes the medication. Which of the following statements by the nurse would be most helpful?"
CHOICES
( X ) a.) "We'll adjust the dose of your medication."
( X ) b.) "Chew the tablet before swallowing it."
( O ) c.) "Take the valproic acid with meals or food."
( X ) d.) "We'll have you take your medication all at one time."
RATIONALE: Valproic acid can be taken with food or at mealtime to minimize gastrointestinal upset. The client's dosage of medication is appropriate, and the serum level is therapeutic between 50 and 100 mcg/mL. The tablets should not be chewed because of possible mouth and throat irritation. Valproic acid is given in two to four doses daily because of its short half-life (6 to 16 hours, peaking in less than 4 hours). NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 508 _ about (MC)
QUESTION: "The nurse would judge client education regarding valproic acid (Depakene) as effective if the client states which of the following?"
CHOICES
( X ) a.) "I can stop the Depakene because the serum level is normal."
( X ) b.) "I can take the Depakene when I feel I need it."
( X ) c.) "Depakene is safe to use when I get pregnant."
( O ) d.) "I might need to take the Depakene for a long time."
RATIONALE: Because bipolar disorder is a biochemical disorder, the client needs to know that she may need medication for a length of time. Stopping the Depakene may cause a return of symptoms. Depakene is never prescribed on an as-needed basis. Careful regular dosing is needed to prevent toxicity, manage symptoms, and balance brain neurotransmitters. It is not safe to take during pregnancy because of risk to the fetus. The client should inform the nurse and physician if she thinks she might be pregnant. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 509 _ about (MC)
QUESTION: "A nurse who makes weekly visits to area boarding homes observes a client who was discharged from a psychiatric hospital. The client is irritable and walks about her room slowly and morosely. After 10 minutes, the nurse prepares to leave, but the client plucks at the nurse's sleeve and quickly asks for help rearranging her belongings. She also anxiously makes inconsequential remarks to keep the nurse with her. In view of the fact that the client has previously made a suicidal gesture, which of the following interventions by the nurse would be a priority at this time?"
CHOICES
( O ) a.) Ask the client frankly if she has thoughts of or plans for committing suicide.
( X ) b.) Avoid bringing up the subject of suicide to prevent giving the client ideas of self-harm.
( X ) c.) Outline some alternative measures to suicide for the client to use during periods of sadness.
( X ) d.) To draw out the client, mention others the nurse has known who have felt like the client and attempted suicide.
RATIONALE: Investigating the presence of suicidal thoughts and plans by overtly asking the client if she is thinking of or planning to commit suicide is a priority nursing action in this situation. Direct questioning about thoughts or plans related to self-harm does not give a person the idea to harm herself. Self-harm is an individual decision. Avoiding the subject when a client appears suicidal is unwise; the safest procedure is to investigate. It would be premature in this situation to outline alternative measures to suicide. Describing other clients who have attempted suicide is too indirect to be helpful and minimizes the client's feelings. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 510 _ about (MC)
QUESTION: "The nurse would be most concerned about a client's depression when the client states that she:"
CHOICES
( X ) a.) Feels tired.
( O ) b.) Has difficulty falling asleep and wakes up early in the morning.
( X ) c.) No longer watches her favorite television programs.
( X ) d.) Is gaining weight.
RATIONALE: Sleep disturbances are markers of the biologic changes associated with depression and indicate increased severity. Feelings of fatigue are common presenting symptoms of depression. Decreased interest in usual activities is a common symptom of depressed mood. Change in appetite is a common symptom of depressed mood. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 511 _ about (MC)
QUESTION: "A client admits to having thoughts of suicide. He is lethargic, withdrawn, and irritable. In conversations with the nurse, he stresses his faults. When he starts to point out the things he cannot do, which of the following responses by the nurse would provide the best intervention?"
CHOICES
( X ) a.) "You can do anything you put your mind to."
( X ) b.) "Try to think more positively about yourself."
( X ) c.) "Let's talk about your plans for the weekend."
( O ) d.) "You were able to write a letter to your friend today."
RATIONALE: Pointing out the client's progress by describing what he can now do is therapeutic. Telling the client that he can do anything he puts his mind to is not therapeutic because it gives false reassurance, is a type of pep talk, and can make him feel guilty for not being able to accomplish things he wants to do. Encouraging him to think more positively about himself can be helpful in countering negative self-talk and boosting self-esteem. However, this client is severely depressed and possibly suicidal. He is unable to think positively about himself or his circumstances. Asking him to do so diminishes his self-worth because he cannot fulfill the nurse's request. Talking about weekend plans may prove more frustrating than helpful for a client who is already finding fault with himself. Suggesting that the client and nurse make plans for the client's weekend also changes the subject the client introduced in the conversation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 512 _ about (MC)
QUESTION: "A client was hospitalized for 1 week with major depression with suicidal ideation. He is taking venlafaxine (Effexor), 75 mg three times a day, and is planning to return to work. The nurse asks the client if he is experiencing thoughts of self-harm. The client responds, "I hardly think about it anymore and wouldn't do anything to hurt myself." The nurse judges:"
CHOICES
( X ) a.) The client to be decompensating and in need of being readmitted to the hospital.
( X ) b.) The client to need an adjustment or increase in his dose of antidepressant.
( O ) c.) The depression to be improving and the suicidal ideation to be lessening.
( X ) d.) The presence of suicidal ideation to warrant a telephone call to the client's physician.
RATIONALE: Evidence that suicidal ideation, although present, is decreasing. The client's statements about being in control of his behavior and his or her plans to return to work indicate an improvement in depression. Nothing in his comments or behavior indicate he is decompensating. There is no evidence to support an increase or adjustment in the dose of Effexor or a call to the physician. Typically, the cognitive components of depression are the last symptoms eliminated. For the client to be experiencing some suicidal ideation in the second week of psychopharmacologic treatment is not unusual. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 513 _ about (MC)
QUESTION: "A client with depression states, "I'm still feeling nauseous after I take Effexor. Maybe I need something else." Which of the following instructions by the nurse would be most accurate?"
CHOICES
( O ) a.) Take the medication at mealtime.
( X ) b.) Take Effexor only in the morning.
( X ) c.) Cut the dose in half.
( X ) d.) Take Effexor before bedtime.
RATIONALE: Nausea is a common side effect of venlafaxine (Effexor); it should be taken at mealtime to minimize gastrointestinal discomfort. Venlafaxine is given in divided doses. The amount should not be taken in one dose because of the drug's 3- to 7-hour half-life in adults (unless it is Effexor extended release [ER]). The dosage should not be halved unless warranted by the client's psychological condition. To be effective, Venlafaxine must be taken in divided doses throughout the day (unless it is Effexor extended release [ER]). NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 514 _ about (MC)
QUESTION: "The depressed client states, "I'm looking forward to going back to work, but I wonder if I'll be able to keep up with the demands of my job." Which of the following statements by the nurse would be most helpful?"
CHOICES
( X ) a.) "You'll do well. You have an excellent work record."
( X ) b.) "I wouldn't worry about it. The main thing to remember is that you can work."
( X ) c.) "You might need extra breaks at first until you feel better."
( O ) d.) "You sound concerned. I want to hear more about how you are feeling."
RATIONALE: Helping the client to express his feelings is an important client goal. Talking about feelings to an accepting, empathetic nurse fosters trust in the caregiver and allows client issues and concerns to surface. Telling the client that he'll do well dismisses his concerns and blocks expression of his anxiety. Telling the client he shouldn't worry about it minimizes his feelings and concerns. The client may interpret the nurse's statements as a message that the nurse does not want to listen to him. Telling the client that he may need extra breaks reinforces the idea that he may not be up to the demands of the job and may increase his concerns. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 515 _ about (MC)
QUESTION: "In general, it is difficult for a nurse to maintain effective relationships with depressed clients experiencing suicidal ideation because of which behaviors?"
CHOICES
( O ) a.) Pessimism arouses frustration and anger in others.
( X ) b.) Poor personal grooming invites disgust and ridicule from others.
( X ) c.) Independence prevents them from asking for assistance.
( X ) d.) Laziness keeps them from putting forth the necessary effort to get well.
RATIONALE: Depressed clients are difficult to relate to because of their hopelessness and general apathy. The concomitant feelings of hopelessness and lack of success experienced by the nurse may lead her to withdraw or to feel angry with the client. Poor personal grooming is typical of clients with depression and suicidal ideation but that can be managed by the nurse. Depressed clients are typically dependent on others. They are not lazy and are usually conscientious and dependable. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 516 _ about (MC)
QUESTION: "The nurse judges correctly that a client is experiencing an adverse effect from amitriptyline hydrochloride (Elavil) when the client demonstrates:"
CHOICES
( X ) a.) An elevated blood glucose level.
( X ) b.) Insomnia.
( X ) c.) Hypertension.
( O ) d.) Urinary retention.
RATIONALE: Urinary retention is a result of the anticholinergic effects of amitryptyline. It is a serious problem in the elderly that should be reported promptly. An elevated blood glucose level is not associated with amitriptyline hydrochloride (Elavil) therapy. Insomnia is not associated with amitriptyline hydrochloride (Elavil) therapy. Hypertension is not associated with amitriptyline hydrochloride (Elavil) therapy. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 517 _ about (MC)
QUESTION: "Which of the following variables should the nurse judge as least likely to indicate high risk when assessing a client's potential for suicide?"
CHOICES
( X ) a.) Age 60 and older.
( O ) b.) Angry behavior.
( X ) c.) Living alone.
( X ) d.) Previous suicidal attempts.
RATIONALE: Anger is a low risk factor for suicide. Risk factors for completed suicide are hopelessness, medical illness, severe anhedonia, male gender, Caucasian or Native American ethno-racial background, living alone, age 60 or older, unemployed, in financial distress, or previous suicide attempt. Age 60 and older is a risk factor for completed suicide. Living alone is a risk factor for completed suicide. Previous suicidal attempt is a risk factor for completed suicide. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control
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--> QUESTION NUMBER _ 518 _ about (MC)
QUESTION: "Which of the following statements is the best wording of a no-harm, no-suicide contract?"
CHOICES
( X ) a.) "I will not think about killing myself."
( O ) b.) "I will not accidentally or purposely kill myself during the next 24 hours."
( X ) c.) "I will not kill myself until after talking to my doctor."
( X ) d.) "I will not kill myself unless my wife dies."
RATIONALE: Agreeing to not kill oneself purposely or accidentally for 24 hours implies agreement to be partly responsible for one's own behavior and safety. In this situation, the nurse would renew the contract each day, if necessary, after assessing the client. Not thinking about killing oneself does not eliminate the possible impulsive behavior or action of self-harm. Agreeing to not kill oneself until after talking to a physician or unless one's spouse dies implies that self-harm is still possible. Agreeing to not kill oneself unless one's spouse dies implies that self-harm is still possible. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 519 _ about (MC)
QUESTION: "The nurse correctly judges that the danger of a suicide attempt is greatest when the client's behavior indicates that he:"
CHOICES
( X ) a.) Has resumed his former lifestyle.
( O ) b.) Has an increased energy level.
( X ) c.) Is at a point of deepest despair.
( X ) d.) Agrees to visit with an estranged brother.
RATIONALE: Suicide attempts are more likely when the client has more energy to act on thoughts and impulses. Resuming a former lifestyle is usually a sign of improvement unless the lifestyle places the client in danger. A client may not have the energy to commit suicide during times of greatest depression. The client's energy level is related to the danger involved. Visiting an estranged sibling does not indicate that a suicide attempt is imminent. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 520 _ about (MC)
QUESTION: "An adolescent girl is brought to the hospital emergency department in a state of unconsciousness after having swallowed "a bottle of pain pills" 45 minutes earlier. The pills are identified as oxycodone (OxyContin). A suicide note is found that asks for forgiveness and states, "I can't live without my boyfriend. He has left me because I'm no good." Which of the following measures should the nurse be prepared to carry out when this client is admitted?"
CHOICES
( X ) a.) Forcing fluids.
( X ) b.) Giving a diuretic.
( X ) c.) Inducing vomiting.
( O ) d.) Giving naloxone (Narcan) IV.
RATIONALE: Narcan is a narcotic antagonist used as an antidote for opioids. Forcing fluids is inappropriate because the client is unconscious. Giving a diuretic will not help eliminate the oxycodone. In an unconscious client, inducing vomiting is inappropriate. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Physiological adaptation
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--> QUESTION NUMBER _ 521 _ about (MC)
QUESTION: "After the client who attempted suicide regains consciousness, she says to the nurse, "I can't even kill myself. I can't even do that right." Which of the following responses by the nurse would be most therapeutic at this time?"
CHOICES
( X ) a.) "These feelings will pass."
( O ) b.) "Tell me more about how you are feeling."
( X ) c.) "Why would you feel that way?"
( X ) d.) "You have a great deal to live for."
RATIONALE: When the client criticizes herself for not being able to commit suicide successfully, it is most therapeutic for the nurse to encourage the client to elaborate and ventilate her feelings. To tell the client that her feelings will pass minimizes these feelings and blocks communication. A comment that includes the word why asks the client to defend her feelings and can cause the client to feel guilty. Telling the client that she has a great deal to live for discounts her feelings. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 522 _ about (MC)
QUESTION: "The client goes to her room and slams the door immediately after the first family therapy session. Later she tells the nurse, "I'm so mad. The therapist didn't let me tell my side of the story. He just agreed with everything my parents said." Which of the following nursing actions would be most therapeutic in this situation?"
CHOICES
( X ) a.) Consider terminating the therapy because it upsets the client.
( O ) b.) Redirect the client to the therapist to tell him how she feels.
( X ) c.) Allow the client to continue to ventilate her feelings to the nurse.
( X ) d.) Suggest to the therapist that he allow the client to tell her side of the story.
RATIONALE: Because self-responsibility is part of the focus of family therapy, direct communication between the people involved in the situation is encouraged. Learning to express oneself clearly and to give direct feedback is part of healthy communication. Here, terminating therapy because it upsets the client, and suggesting to the therapist that the client be allowed to speak does not allow the client to deal directly with the person she is angry with and discourages the client from taking responsibility for her own feelings. It is satisfactory to allow a client to ventilate to a nurse; however, in this situation it would be best for the client to have open communication with her therapist. Suggesting to the therapist that the client be allowed to speak does not allow the client to deal directly with the person she is angry with and discourages the client from taking responsibility for her own feelings. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 523 _ about (MC)
QUESTION: "A client with a self-inflicted gunshot wound in his arm is brought to the inpatient psychiatric unit from the emergency department. With his arm bandaged and in a sling, he is escorted to the unit by emergency department staff. A staff member states to the nurse, "He only hurt his arm so he probably only wanted to manipulate someone or did it for attention." Which of the following responses by the nurse to the staff member would be most appropriate?"
CHOICES
( O ) a.) "All suicide attempts or acts of self-harm are very serious and indicate a cry for help."
( X ) b.) "He really must not have wanted to kill himself, but he certainly injured his arm."
( X ) c.) "He didn't use a lethal method to kill himself, so he must not have been serious about taking his life."
( X ) d.) "It was probably a way to escape a serious problem. The hospital is a safe and secure environment."
RATIONALE: The nurse must always consider all suicide attempts as very serious. Even though the attempt may result in minimal injury, it is still a cry for help and an extremely dysfunctional method of coping. Discounting the injury minimizes the client's pain and disregards his intent. Using a gun is a high-risk and lethal method of suicide. Even if a client is ambivalent about suicide, accidental suicide results in loss of life. To think of a suicide as a way to escape a serious problem or a means to gain attention is irresponsible and leads to unsafe nursing practice such as ignoring warning signs of suicidal attempts. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 524 _ about (MC)
QUESTION: "What client behaviors would be most important for the nurse to consider in deciding to institute suicide precautions because of high-risk behavior?"
CHOICES
( X ) a.) The client still has thoughts of harming himself but feels he can control them.
( X ) b.) The client is worried about his child's reaction.
( X ) c.) He expresses guilt and shame about trying to harm himself.
( O ) d.) He has recently attempted suicide with a lethal method.
RATIONALE: A recent suicide attempt using a lethal method always indicates the need for suicide precautions. The client is at high risk for suicide, and his life must be protected and safety maintained. Having feelings of being in control of suicidal thoughts indicates a lower risk for suicide. Worrying about a child's reaction indicates a lower risk for suicide. Expressing guilt and shame about the suicide attempt indicates a lower risk for suicide. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 525 _ about (MC)
QUESTION: "A client is having a severe reaction to cocaine and seems to have lost touch with reality. He is very suspicious of his friends who came with him and does not want to talk to the nurse. Suddenly, he yells out, "I'll kill you before I'll let you take me." Which of the following comments by the nurse would be most useful to help the client reestablish his self-control and orientation?"
CHOICES
( X ) a.) "You have no need to be concerned. You're going to be all right."
( X ) b.) "You have taken a drug you shouldn't have, and it is making you sick."
( O ) c.) "You're reacting to the cocaine and will soon be past the main drug reaction. You're safe here."
( X ) d.) "You have a temporary psychosis from taking a psychedelic. Let's watch some television while we wait for it to pass."
RATIONALE: To help the client reestablish self-control and orientation, it would be best for the nurse to make a truthful statement about what is happening and to explain what to expect. Telling the client that he has no need for concern offers false assurance. It is not helpful to moralize by berating the client for what he did. A statement with technical terms that the client may not understand is futile. Television is generally contraindicated for a client suffering ill effects after using cocaine. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 526 _ about (MC)
QUESTION: "A client has a perforated nasal septum. The nurse correctly judges the client to be a user of which of the following substances?"
CHOICES
( X ) a.) Heroin.
( O ) b.) Cocaine.
( X ) c.) Marijuana.
( X ) d.) LSD.
RATIONALE: Nasal septal perforation is associated with cocaine uses. When the cocaine is inhaled into the nares, it causes vasoconstriction and impairs the blood supply to the septum. With frequent repeated use, this leads to tissue necrosis. Heroin is not inhaled through the nose but is taken orally or intravenously. Marijuana is smoked, not snorted. LSD is taken orally. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 527 _ about (MC)
QUESTION: "The family members of the victims of a three-car accident have arrived at the emergency department. The wife of one accident victim is sitting away from the others and crying. Which of the following actions by the nurse would be best?"
CHOICES
( X ) a.) Leave the wife alone to cry.
( O ) b.) Sit next to the wife and offer her some tissues.
( X ) c.) Call the physician for a sedative.
( X ) d.) Ask the wife if she would like to speak to the social worker.
RATIONALE: Conveying warmth, empathy, and support to the wife to encourage the release of feelings is a priority nursing action at this time. Leaving her alone to cry without offering help is inappropriate behavior by the nurse. Calling the doctor for something to sedate the wife may be necessary and appropriate later. Asking her if she would like to speak to the social worker may be necessary and appropriate later. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
******************************
--> QUESTION NUMBER _ 528 _ about (MC)
QUESTION: "A client scans the adult inpatient unit on his arrival at the hospital. He is neatly dressed and clutches a leather briefcase tightly in his arms. The client refuses to let the nurse touch his briefcase or check it for valuables or contraband. Which of the following actions by the nurse would be best?"
CHOICES
( X ) a.) Obtaining help to take the briefcase away from the client.
( O ) b.) Asking the client to open the briefcase while he describes its contents.
( X ) c.) Inspecting the briefcase when the client is temporarily out of the room.
( X ) d.) Telling the client that he must follow hospital policy if he wishes to stay.
RATIONALE: When a client refuses to have his belongings checked for valuables or contraband according to hospital policy, the least-threatening course of action is to ask him to open his briefcase while he describes its contents. Getting help to take the briefcase away from the client is a threatening maneuver. Inspecting the briefcase while the client is out of his room involves secrecy and is less desirable than an open discussion with the client. Telling the client that he must observe hospital policy to stay is threatening and probably inaccurate as well. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
******************************
--> QUESTION NUMBER _ 529 _ about (MC)
QUESTION: "As the nurse stands near the window in the client's room, the client shouts, "Come away from the window! They'll see you!" Which of the following responses by the nurse would be best?"
CHOICES
( O ) a.) "Who are 'they?'"
( X ) b.) "No one will see me."
( X ) c.) "You have no reason to be afraid."
( X ) d.) "What will happen if they do see me?"
RATIONALE: Asking the client who "they" are when he is fearful helps the nurse understand his behavior and is least demanding of the client. The client is unlikely to accept statements that indicate that no one will see the nurse and that there is no reason to be afraid. The client is unlikely to accept statements that there is no reason to be afraid. Asking the client what will happen if someone sees the nurse is also unlikely to be acceptable and validates the client's delusion. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
******************************
--> QUESTION NUMBER _ 530 _ about (MC)
QUESTION: "The client thinks he is being followed by foreign agents who are after secret papers in his briefcase. What thought disorder does this indicate?"
CHOICES
( X ) a.) Idea of reference.
( X ) b.) Idea of influence.
( X ) c.) Delusion of grandeur.
( O ) d.) Delusion of persecution.
RATIONALE: The client's thought process is best defined as a delusion of persecution. An idea of reference assumes that the remarks and behavior of others apply to oneself. An idea of influence refers to the belief that people or objects have control over one's behavior. A delusion of grandeur involves an exaggerated idea of one's importance or identity. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
******************************
--> QUESTION NUMBER _ 531 _ about (MC)
QUESTION: "The client was admitted to the psychiatric unit yesterday evening. In the morning, the client approaches the nurse and states, "The doctor and all of you nurses are conspiring against me. I've been warned and I know it's true. You know what I mean." Which of the following responses by the nurse would be most therapeutic?"
CHOICES
( X ) a.) "That simply isn't true. Just stay calm."
( X ) b.) "I'll see if I can find your doctor for you."
( X ) c.) "I don't know what you mean, but you're secure here."
( O ) d.) "You must feel very frightened. You're safe here."
RATIONALE: The nurse verbalizes the feelings conveyed by the client or the impact the delusion has on the client. Assure the client he is safe and no harm will come to him. Reasoning, arguing, challenging, or trying to disprove the client's delusion may force the client to adhere to and defend it. It is not therapeutic to disagree with the client's delusions because challenging the delusion will force the client to defend it. Telling the client that you will find his doctor ignores him and conveys nonacceptance. Telling the client that you don't know what he means ignores his needs and conveys nonacceptance as an individual. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
******************************
--> QUESTION NUMBER _ 532 _ about (MC)
QUESTION: "The client is suspicious of staff members and other clients. To help establish a therapeutic relationship with the client, which of the following plans would be best?"
CHOICES
( X ) a.) Initiate conversations with the client whenever he becomes agitated.
( O ) b.) Spend brief intervals with the client each day.
( X ) c.) Allow the client to initiate conversations when he feels ready for them.
( X ) d.) Do not approach the client for interactions until he has been stabilized on medications.
RATIONALE: To promote a therapeutic relationship with a suspicious client, it is best to spend brief intervals with the client each day to develop trust, respect, and rapport. It is difficult to have meaningful conversations that promote a therapeutic relationship when meetings occur only when the client is agitated, although the nurse may need to intervene at those times as well. It is inappropriate to wait until the client initiates meetings because nonthreatening interactions help to establish trust and rapport. It is inappropriate, not therapeutic, and impractical to wait until the client is stabilized on medication before interacting with him. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
******************************
--> QUESTION NUMBER _ 533 _ about (MC)
QUESTION: "The nurse observes that a client on a psychiatric unit is looking around the room with eyes darting to a chair in the corner. The client grimaces then states, "Bastard," under his breath. Which of the following nursing actions is most appropriate?"
CHOICES
( X ) a.) Ignore the client because he appears to be hallucinating.
( O ) b.) Approach the client to interrupt the hallucinations.
( X ) c.) Suggest the client spend some time in his room.
( X ) d.) Remind the client that vulgar language is not appropriate in the hospital.
RATIONALE: The nurse intervenes with the client experiencing hallucinations to assist with increasing the client's awareness that the hallucinations are not part of reality but are a symptom of illness. The nurse does not ignore the client because the hallucinations can continue and escalate. Sending him to his room ignores the client's need, permits him to engage in his psychosis, increases confusion, and increases withdrawn behavior. Stating that vulgar language is not permissible ignores and dismisses the client. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 534 _ about (MC)
QUESTION: "A client is to receive haloperidol (Haldol). To prevent the client from possibly "cheeking" the medication, the drug should be given in which form?"
CHOICES
( O ) a.) Liquid.
( X ) b.) Tablet.
( X ) c.) Suppository.
( X ) d.) Intramuscular injection.
RATIONALE: It is generally best to try giving a medication in its liquid form if the client fights taking it. Tablets are easy to hide in the mouth to be discarded later or saved for later use. Haldol is not available in suppository form. If he refuses to swallow or expectorates the medication, the intramuscular route can be used if ordered by the physician, although that too will probably meet with resistance. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 535 _ about (MC)
QUESTION: "After 3 days of taking haloperidol, the client shows an inability to sit still, is restless and fidgety, and paces around the unit. The client is showing signs of which of the following extrapyramidal adverse reactions?"
CHOICES
( X ) a.) Dystonia.
( O ) b.) Akathisia.
( X ) c.) Parkinsonism.
( X ) d.) Tardive dyskinesia.
RATIONALE: The client's behavior is best defined as akathisia, or motor restlessness, and a compulsion to move constantly. Dystonia is characterized by uncoordinated spasmodic movements. Parkinsonism is characterized by decreased mobility, muscle rigidity, and tremors. Tardive dyskinesia is characterized by twitching or involuntary muscular movement. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
******************************
--> QUESTION NUMBER _ 536 _ about (MC)
QUESTION: "A 20-year-old client with paranoid schizophrenia is in the fourth day of hospitalization. The client's parents visit and state to the nurse, "What did we do wrong? What caused this awful thing to happen?" Which of the following explanations by the nurse is most accurate and therapeutic?"
CHOICES
( X ) a.) "We really don't know. There are many theories about schizophrenia."
( X ) b.) "Let's talk about your family background. Schizophrenia is often genetic."
( O ) c.) "You didn't cause schizophrenia by doing something wrong. Schizophrenia is a biologic brain disease and can be caused by biochemical and structural changes in the brain."
( X ) d.) "Try not to worry. Paranoid schizophrenia has a good prognosis."
RATIONALE: The nurse is sensitive to the parents' feeling of guilt and lack of knowledge about the etiologies of schizophrenia. The nurse reassures the parents that they are not to blame for their daughter's illness. Then she begins to educate them by explaining the biologic theories of the disease in a simple, straightforward manner. This response ignores the parents' concerns and diminishes trust in the nurse by not offering accurate information about the disorder. This response implies that the parents are to blame and offers an incomplete explanation of the disorder. This response placates the parents and does not help them with their feelings. The nurse cannot accurately state what the prognosis will be or predict the client's response to medications and treatment. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 537 _ about (MC)
QUESTION: "The client with a diagnosis of Axis I Paranoid Schizophrenia spends much of the morning in his room but seeks out the nurse for brief interactions throughout the morning. Which of the following expected outcomes would the nurse assist the client with achieving in the afternoon? "
CHOICES
( X ) a.) Participate in the community meeting.
( X ) b.) Volunteer to organize an evening of games with his peers.
( O ) c.) Help put a puzzle together with the nurse.
( X ) d.) Engage three of his peers in a card game.
RATIONALE: The nurse uses approaches to assist the client who is suspicious, fearful, and withdrawn to feel a measure of trust, comfort, and security on a one-to-one basis. Attending and interacting in groups are too overwhelming for the client and can result in increased anxiety, fear, and withdrawal. Leading or organizing activities is too overwhelming for the client and can result in increased anxiety, fear, and withdrawal. Interacting with peers will follow, once trust in the staff and the environment has been established. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 538 _ about (MC)
QUESTION: "A mute client begins to express herself verbally on occasion. Which of the following nursing actions should be credited with helping a mute client express herself verbally?"
CHOICES
( X ) a.) Asking direct questions that draw the client out.
( X ) b.) Using hand signals to entice the client to communicate.
( O ) c.) Making open-ended statements followed with silence.
( X ) d.) Expressing perceptions about what the client is experiencing.
RATIONALE: The best approach for a client who has difficulty expressing herself verbally is to use an undemanding, open-ended statement. When the client is ready to talk, the silences following the statement will give her the opportunity to do so. Asking the client direct questions may be too intimidating and yield only yes or no answers. Using hand signals is not likely to be effective. No one individual can know what another is experiencing and it is rude to presume to know. This is sometimes referred to as claiming the client's feelings. It can lead to the client's anger or resentment. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 539 _ about (MC)
QUESTION: "A client often does the opposite of what she is requested to do. For example, if asked to stand up, she sits down; if asked to dress, she undresses. In view of the client's negativism, which of the following actions would be best for the nurse to take to get the client to the dining room for meals?"
CHOICES
( X ) a.) Ask her to eat in her room away from the other clients.
( X ) b.) Wait for her to get hungry enough to come to the dining room by herself.
( O ) c.) Tell her it is time for lunch and guide her to the dining room.
( X ) d.) Promise her a reward if she eats in the dining room and get help to take her there if she refuses.
RATIONALE: The best course of action is to guide the client to the dining room. This type of positive and firm approach is also needed to help increase the client's socialization. It is inappropriate to exclude the client and increases the client's withdrawal. The client simply may not eat if allowed to decide when to go to the dining room. Punishment and reward are likely to be of little value when a client does the opposite of what she is asked to do. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 540 _ about (MC)
QUESTION: "When upset, the client curls into a fetal position in bed. The nurse judges the client to be exhibiting which of the following?"
CHOICES
( X ) a.) Fixation.
( O ) b.) Regression.
( X ) c.) Substitution.
( X ) d.) Symbolization.
RATIONALE: A client's behavior is best described as regression when it is typical of an earlier stage of development. Fixation means not progressing beyond a given level of development. Substitution means replacing unacceptable ideas with more acceptable ones. Symbolization occurs when one idea or object comes to stand for another. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 541 _ about (MC)
QUESTION: "The client is brought to the hospital from a group home where she became agitated and threw a chair at another client. She has refused medication for 8 weeks and refuses to care for her hygiene. The client exhibits a flat affect and has become increasingly withdrawn and asocial. The physician orders risperidone (Risperdal) 1 mg PO bid for the client on admission to the hospital. The nurse judges this dose to be:"
CHOICES
( X ) a.) Too high for the client.
( X ) b.) Too low for the client.
( O ) c.) Typical when initiating therapy.
( X ) d.) Typical for initiating therapy but it should be tapered down in 1 week.
RATIONALE: Treatment with risperidone (Risperdal) typically begins with 0.5 to 1 mg bid and is slowly increased over the first week (to minimize the risk of postural hypotension) to 3 mg/day. The client is maintained on this dose for at least 1 week before further adjustments in dosage are made. Recommended dosages range from 4 to 6 mg/day. This dosage is not too high for the client. This dosage is not too low for initial treatment. It is typical for initiation, but dosage will be increased, not decreased, over 1 week. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 542 _ about (MC)
QUESTION: "A client suddenly behaves in an impulsive, hyperactive, unpredictable manner. Which of the following approaches would be best for the nurse to use first if the client becomes violent?"
CHOICES
( X ) a.) Provide a physical outlet for the client's energies.
( X ) b.) Let the client know that her behavior is not acceptable.
( O ) c.) Get help to handle the situation safely.
( X ) d.) Use heavy sedation to keep the client calm.
RATIONALE: The recommended first course of action is to prevent accidents and injuries when a client becomes violent. In this situation, it would be best to call for help to handle the situation safely. This an appropriate course of action but only after the situation is safely under control. This is an important useful intervention but is not likely to be useful in an unstable, escalating situation. Heavy sedation to control behavior is not the nurse's first course of action. The first course of action is to summon help. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 543 _ about (MC)
QUESTION: "A client comes to the outpatient mental health clinic 2 days after being discharged from the hospital. The client was given a 1-week supply of clozapine (Clozaril). The nurse reviews information about clozapine with the client. Which client statement indicates an accurate understanding of the nurse's teaching about this medication?"
CHOICES
( X ) a.) "I need to call my doctor in 2 weeks for a checkup."
( O ) b.) "I need to keep my appointment here at the hospital this week for a blood test."
( X ) c.) "I can drink alcohol with this medication."
( X ) d.) "I can take over-the-counter sleeping medication if I have trouble sleeping."
RATIONALE: Mandatory weekly white blood cell counts are used to detect developing agranulocytosis, which can be fatal and occurs in 1% to 2% of clients taking clozapine. This medication is associated with risk of seizures; this risk is dose-dependent, meaning that it increases in moderate to high doses (600 to 900 mg/day). While this may be true, it does not reflect an understanding of the medication. Use of alcohol is contraindicated. Use of over-the-counter medications is contraindicated. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 544 _ about (MC)
QUESTION: "A client is admitted to the unit with a diagnosis of Delusional Disorder, Persecutory Type. The nurse appraises the client's thought content to include nonbizarre delusions. Which of the following statements by the client validates the nurse's judgment?"
CHOICES
( X ) a.) "Aliens from outer space are following me."
( O ) b.) "My neighbor is trying to steal my land. He is going to move his fence to impinge on my property."
( X ) c.) "My wife is being unfaithful and I have proof. She's seeing other men."
( X ) d.) "No one knows but I'm the President's most secret top adviser."
RATIONALE: Delusional Disorder is marked by nonbizarre delusions with the absence of other characteristic symptoms of the active phase of schizophrenia. The statement "My neighbor is trying to steal my land by moving his fence" is an example of Delusional Disorder, Persecutory Type. This is a bizarre delusion and not believable. This statement is more specific to Delusional Disorder, Jealous Type. This statement is more specific to Delusional Disorder, Grandiose Type. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 545 _ about (MC)
QUESTION: "A client with a chronic mental illness has worked as a hotel maid for the past 3 years. She tells the nurse she is thinking of quitting her job because "voices on television are talking about me." What would be the nurse's initial action?"
CHOICES
( O ) a.) Obtain information about the client's medication compliance.
( X ) b.) Remind the client that hearing voices is a symptom of her illness with which she can cope.
( X ) c.) Check with the client's employer about her work performance.
( X ) d.) Arrange for the client to be admitted to a psychiatric hospital for a short stay.
RATIONALE: Symptom exacerbation is most often related to noncompliance with the prescribed medication regimen. Therefore, obtaining information about the client's compliance is the first priority. Helping the client recognize the symptoms and her ability to manage them is appropriate but this is not the first priority. Checking with her employer is not appropriate and does not help the client with management of her illness. Hospitalization is not indicated because the client is still working and can talk about the symptoms. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 546 _ about (MC)
QUESTION: "The client tells the nurse that she stopped taking chlorpromazine hydrochloride (Thorazine) 2 weeks ago because she is better and wants "to make it on my own without this darned medicine." Which of the following would be the nurse's most therapeutic response?"
CHOICES
( X ) a.) "You've told me about other times like this when you stopped taking your medication and got sick again. Please don't do it again this time."
( X ) b.) "You're a smart girl. You know what will happen if you don't take your medication. Why do you want to be so bad to yourself?"
( O ) c.) "I know you get tired of taking the medication, especially when you're doing well. Is there any special reason you decided to stop right now?"
( X ) d.) "Maybe you're ready for a short holiday from the Thorazine. I'll talk it over with the physician. But you need to keep taking it until I talk with the doctor."
RATIONALE: Recognizing the client's feeling and her progress while obtaining more information is the most therapeutic response. Reminding the client of her previous related experience is also appropriate but could be done more therapeutically. Challenging the client and asking questions designed to make her feel guilty is not therapeutic and is not likely to improve medication compliance. To suggest the possibility of a drug holiday when symptoms are recurring is clinically unsound. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 547 _ about (MC)
QUESTION: "A client who has been staying at a local hotel for 3 days is brought to the mental health center by a police officer because she has been bothering other people when she eats in the hotel restaurant. She denies this, will not give her name, and holds tightly to her purse. She refuses to talk to anyone except to say, "You have no right to keep me here. I have money, and I can take care of myself." The police can hold her for disturbing the peace but think she needs psychiatric evaluation. Which of the following factors would be most relevant to a decision about this client's disposition?"
CHOICES
( O ) a.) She seems able to care for herself.
( X ) b.) She has no known family.
( X ) c.) She is not known to the mental health center.
( X ) d.) She has $500 in cash and wants to go back to the hotel.
RATIONALE: This client's ability to care for herself is most relevant to a decision about her disposition. Whether or not the client has a family is not pertinent to this situation. The need for psychiatric evaluation is dependent on the client's needs, not on the family. If she is gravely disabled or needs treatment to care for herself, involuntary hospitalization is indicated whether or not she is known to the mental health center. Having monetary resources does not necessarily mean that she will be able to use them to care for herself. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 548 _ about (MC)
QUESTION: "The decision is made to involuntarily admit a client to a psychiatric hospital on an emergency basis. The nurse on the inpatient unit explains the involuntary hospitalization process to the client, who listens quietly. Which of the following statements made by the nurse would be inaccurate?"
CHOICES
( X ) a.) "You're in the hospital because the psychiatrist who saw you earlier thinks that you are unable to care for yourself right now."
( X ) b.) "You're free to talk to a lawyer if you'd like to do so."
( X ) c.) "You cannot leave the hospital until the doctor or a judge thinks you can take care of yourself."
( O ) d.) "You cannot have any visitors while you're here involuntarily."
RATIONALE: Clients have a right to see visitors regardless of admission status. Involuntary hospitalization requires a psychiatrist state-of-need. Any client admitted involuntarily has the right to legal counsel. Release requires medical or legal approval. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 549 _ about (MC)
QUESTION: "As the nurse helps the client prepare for discharge, the client says, "You know, I've been in lots of hospitals and I know when I'm sick enough to be there. I'm not that sick now. You don't need to worry about me." Which of the following would be the most therapeutic response by the nurse?"
CHOICES
( O ) a.) "We're concerned about you. How can we help you before you leave?"
( X ) b.) "We could have helped you more if you had told us more."
( X ) c.) "Is there any information you need before you leave the hospital?"
( X ) d.) "Okay, you know best."
RATIONALE: It is most therapeutic to let the client know of the staff's continued concern and to ask her what might be useful to her. Making the point that she did not use the hospital well is not therapeutic on discharge. Asking if the client needs any information is certainly helpful but is not as therapeutic as demonstrating concern and offering help. This response dismisses the client and does not foster further interaction with the nurse about any additional concerns. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 550 _ about (MC)
QUESTION: "The nurse at the mental health center has been asked to develop a staff in-service program about adult clients with schizophrenia. Which of the following characteristics would the nurse most likely find common to this group of clients?"
CHOICES
( O ) a.) Medication noncompliance is the primary cause of relapse.
( X ) b.) They have little difficulty in work situations.
( X ) c.) They have a low incidence of substance abuse.
( X ) d.) They seldom experience depression.
RATIONALE: Noncompliance is the major cause of relapse and readmittance to the hospital. The inability to cope socially on the job is a major obstacle to a productive work life for clients with schizophrenia. Substance abuse is common in this client population. Depression is frequently a part of the psychopathology of schizophrenia. It may be marked during the acute phase of the disorder. It may be a reaction to having a mental illness. Medication to treat schizophrenia may induce a depressive syndrome. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care
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--> QUESTION NUMBER _ 551 _ about (MC)
QUESTION: "A 72-year-old female client is brought by ambulance to the hospital's psychiatric unit from a nursing home where she has been a client for 3 months. Transfer data indicate that she has become increasingly confused and disoriented. In which of the following ways should the hospital admission routine be modified for the client?"
CHOICES
( X ) a.) Leave her alone to promote recovery of her faculties and composure.
( X ) b.) Medicate her to ensure her calm cooperation during the admission procedure.
( O ) c.) Allow her sufficient extra time in which to gain an understanding of what is happening to her.
( X ) d.) Give her a tour of the unit to acquaint her with the new environment in which she will live.
RATIONALE: When admitting an elderly client, especially one who is confused and disoriented, it is best to give the client extra time in which to gain an understanding of what is happening to her. This will help her to get her bearings and adjust to a new environment. Leaving the client alone will not help her confusion and disorientation and will increase her fear and anxiety. Medication would not be appropriate until the cause of her confusion and disorientation is determined. Over-medicating elderly clients is sometimes a cause of their confusion. A tour of the unit will not be helpful for the client who is confused and disoriented. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 552 _ about (MC)
QUESTION: "The client is to undergo a series of diagnostic tests to determine if her cognitive impairment is treatable. Which of the following states can lead to nonreversible cognitive impairment?"
CHOICES
( X ) a.) Cerebral abscess.
( O ) b.) Multiple sclerosis.
( X ) c.) Syphilitic meningitis.
( X ) d.) Electrolyte imbalance.
RATIONALE: Multiple sclerosis is a progressive chronic disease; its course cannot be reversed, although clients may experience periodic remissions. Cerebral abscess is a treatable cause of cognitive impairment. Syphilitic meningitis is treatable. Electrolyte imbalance is treatable. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 553 _ about (MC)
QUESTION: "A 22-year-old client exhibits memory loss, confusion, and wandering behavior. Of the following comments by the nurse, which would provide the best reality orientation for the client when she first awakens in the morning?"
CHOICES
( X ) a.) "Do you remember who I am or what day it is today?"
( X ) b.) "Hello, did you sleep well? Which dress would you like to wear today, the yellow or the green one?"
( X ) c.) "Here I am again, your favorite nurse. There will be pancakes for breakfast this morning."
( O ) d.) "Good morning. This is your second day in Memorial Hospital and I'm your nurse for today. My name is Rachel."
RATIONALE: To promote reality orientation, the nurse should be as specific as possible when addressing a confused and disoriented client. Such comments as indicating what day it is, where the client is, and the nurse's name can help. Asking the client questions about her environment is likely to be challenging and may decrease the client's self-esteem. The nurse needs to establish her identity to decrease confusion and to ask one question at a time to promote concentration and decrease confusion. The nurse needs to establish her identity to decrease confusion. It is not helpful to provide mostly irrelevant information. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 554 _ about (MC)
QUESTION: "A client roams about the nursing home at night, disturbing other clients. When asked why she walks about, she complains of being lost and unable to sleep. A large sign is posted on the door of her room to help her locate it. Which of the following programs would be best for addressing the client's insomnia?"
CHOICES
( X ) a.) A daily afternoon nap to prevent over tiredness at night.
( X ) b.) Administration of a hypnotic drug at bedtime.
( O ) c.) Enough active exercise daily so she will be comfortably tired at night.
( X ) d.) A cup of hot tea with lemon before bed to promote a feeling of well-being.
RATIONALE: A client with insomnia is more likely to sleep well if she feels tired at bedtime, which is likely if she had enough daily exercise so that she is comfortably tired at night. Having the client take a daily afternoon nap is likely to interfere with night-time sleep. Sedatives should be used only as a last resort because they are likely to be habit-forming. Offering the client tea at bedtime is unlikely to promote sleep, especially if the tea contains caffeine, which may lead to further wakefulness. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 555 _ about (MC)
QUESTION: "A client's daughter says that her mother wore the same dirty, worn-out undergarments for weeks at home. Of the following techniques, which would be best for the nurse to follow with the client during hospitalization to prevent further regression in her personal hygiene habits?"
CHOICES
( X ) a.) Accept her need to go without bathing if she so desires.
( X ) b.) Make her assume responsibility for her own physical care.
( O ) c.) Encourage her to do as much self-care as she can.
( X ) d.) Do most of her physical care while letting her think she did it herself.
RATIONALE: The best procedure for helping the client to remain independent and observe good hygiene habits is to encourage her to do as much self-care as she is capable of doing. For this client, it would be inappropriate to accept her poor personal hygiene habits. It would be impractical and unrealistic to expect the client to start taking care of all her hygiene needs. To do all of the client's hygienic care would cause further dependence, and it would be dishonest to care for the client while letting her think she did it herself. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 556 _ about (MC)
QUESTION: "A client asks the nurse to help her make out her will. Which of the following possible responses by the nurse would be best in this situation?"
CHOICES
( X ) a.) "I'm not a lawyer, but I'll do what I can for you."
( X ) b.) "You have a long way to go before you'll need to do that. Let's wait on it a while, shall we?"
( X ) c.) "I don't believe in getting involved in legal matters, but maybe I can find another nurse who'll help you"
( O ) d.) "You need to consult an attorney because I'm not trained in such matters. Is there a family lawyer I can call for you?"
RATIONALE: A will is an important legal document. It is best to have one prepared with the help of an attorney. It would be unwise to help the client because a nurse is not a lawyer. Asking the client to delay preparing the will just avoids the problem. It is also not helpful to seek out another nurse to help the client prepare a will. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care
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--> QUESTION NUMBER _ 557 _ about (MC)
QUESTION: "The daughter of a client with mild Alzheimer's disease tells the nurse that her mother thinks someone is stealing her things. Which of the following responses by the nurse would be most helpful?"
CHOICES
( X ) a.) "That behavior is typical of people with Alzheimer's and will only get worse."
( O ) b.) "Your mother has problems with remembering where she puts things. This may be causing her to think someone is stealing them."
( X ) c.) "Perhaps your mother is imagining things."
( X ) d.) "Your mother is having delusions, which are firm, false beliefs."
RATIONALE: The best response explains that cognitive deficits and memory loss lead the client to forget where she placed something and may lead to accusations of someone stealing her possessions. Stating that the behavior is typical of someone with Alzheimer's disease dismisses the daughter, is not helpful, and does not increase the daughter's knowledge about the disease. This is not her imagination, but a response to not being able to remember. These are not delusions or her imagination but a reaction to not being able to remember. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 558 _ about (MC)
QUESTION: "The nurse assesses a client who has Alzheimer's disease. Her hair is dirty; her clothing is soiled and has an odor of urine. The nurse's best action would be to:"
CHOICES
( X ) a.) Ask the client when was the last time she bathed and changed her clothes.
( O ) b.) Help the client with her bath, allowing her to do as much for herself as she is able.
( X ) c.) Ask the daughter to bathe her mother.
( X ) d.) Instruct the client to bathe and put on clean clothing.
RATIONALE: To foster independence, the best action would be for the nurse to help the client bathe and dress, allowing the client to do as much for herself as she is able. Asking the client when she bathed last is futile because the client may not remember. It may also embarrass the client and decrease her self-esteem. Asking the daughter to bathe her mother fosters dependence on the daughter. Instructing the client to do her activities of daily living is not appropriate or helpful as the client is now unable to do so because of the disease process and changes in mentation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 559 _ about (MC)
QUESTION: "The client with Alzheimer's disease has been prescribed donepezil (Aricept), 5 mg hs. The nurse instructs the daughter:"
CHOICES
( X ) a.) To take her mother to the clinic next week for blood work.
( X ) b.) To give her mother an extra dosage if needed at night.
( X ) c.) To observe her mother for signs of constipation.
( O ) d.) To avoid suddenly stopping the medication.
RATIONALE: Abrupt cessation of Aricept may result in rapid deterioration of client functioning. Aricept does not cause liver toxicity, so monitoring of blood serum levels is not necessary. Extra doses of Aricept are not given on an as-needed basis. Aricept is more likely to produce diarrhea than constipation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 560 _ about (MC)
QUESTION: "A client exhibits confusion and severe memory loss. At 11:30 AM, he tells the nurse that he is going to work and proceeds to walk toward the door. The nurse should take which of the following actions?"
CHOICES
( X ) a.) Remind him that he retired from his job 10 years ago.
( X ) b.) Tell him that she'll accompany him for a short walk outdoors.
( O ) c.) Divert his attention toward the dining room where lunch is being served.
( X ) d.) Tell him that he does not have to go to work today.
RATIONALE: The client can be helped most by diverting his attention toward an activity in the milieu or with the nurse. Reminding the client with severe memory loss that he retired from his job 10 years ago will not help him and may increase his frustration. Telling the client that the nurse will accompany him for a short walk outdoors reflects poor judgment by the nurse and may compromise the client's safety because the client with a cognitive impairment could misinterpret the walk as going to work. He could become agitated and compromise his and the nurse's safety. Telling the client that he does not have to work today is a falsehood that should be avoided. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 561 _ about (MC)
QUESTION: "For the client experiencing delirium, the nurse prioritizes interventions to first maintain:"
CHOICES
( X ) a.) Orientation.
( O ) b.) Physical safety.
( X ) c.) Optimal level of functioning.
( X ) d.) Consistency in routine.
RATIONALE: Nursing interventions that maintain physical safety are a priority for the client with delirium, who, in a delirious state, is at increased risk of injury. Facilitating orientation is important only after physical safety has been assured. Maintaining an optimal level of functioning is the primary goal for a client with dementia. Consistency in daily routine is of less importance when caring for a client with delirium. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 562 _ about (MC)
QUESTION: "In closed or locked units, the nurse judges the milieu as therapeutic because priorities are given to:"
CHOICES
( X ) a.) Socialization and self-understanding.
( X ) b.) Education and vocation counseling.
( O ) c.) Safety, structure, and support.
( X ) d.) Developing communication, social, and leisure skills.
RATIONALE: Clients on a closed or locked inpatient psychiatric unit are typically acutely ill. Providing safety, structure, and support are immediate priorities in the therapeutic milieu for clients with cognitive impairment and inability to handle stress. Socialization and self-understanding are not the priorities of treatment and the milieu on a locked unit. Education and vocational counseling will be addressed when the client is discharged from inpatient status and referrals are made along the continuum of care. Developing leisure, social, and communication skills is important, but not the priority. As clients improve, they become better organized in their thinking and more capable of tolerating stress. They would then be more apt to benefit from such groups and therapies at that time. These activities are part of the therapeutic milieu. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 563 _ about (MC)
QUESTION: "A client diagnosed with a cognitive disorder is showing signs of confusion and a short attention span. Which of the following activities would be best suited for this client? "
CHOICES
( X ) a.) Join others going on a field trip.
( X ) b.) Become a member in group therapy.
( X ) c.) Meet with an assertiveness training group.
( O ) d.) Participate in a reality-orientation group.
RATIONALE: Because the client has confusion and a short attention span and lacks concentration, a reality-orientation group is recommended to help her maintain an optimal level of functioning. Going on a field trip will likely be too stressful for the client. Entering group therapy is not therapeutic due to the client's decreased attention span and confusion. Meeting with an assertiveness training group is likely to be too stimulating to the client and may increase her frustration and decrease her sense of accomplishment. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 564 _ about (MC)
QUESTION: "A 5-year-old child exhibits signs of extreme restlessness, short attention span, and impulsiveness. Which of the following ways could the nurse alter the child's milieu that would likely be most therapeutic for him?"
CHOICES
( X ) a.) Increase the child's sensory stimulation.
( X ) b.) Limit the child's opportunities to verbalize anger and frustration.
( O ) c.) Define behaviors of the child that will be acceptable and those that will be unacceptable.
( X ) d.) Restrict the child's participation in physical activities.
RATIONALE: Children need to know what behaviors are acceptable and what behaviors are unacceptable. They feel more secure when limits are clear and when policies concerning their behavior are consistently enforced. Increasing sensory stimulation tends to increase hyperactive and impulsive behavior. Limiting opportunities to verbalize anger and frustration tends to increase stress and frustration for the child. Physical activities are needed to help the child expend energy, reduce anxiety, and increase self-worth. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 565 _ about (MC)
QUESTION: "An attitude by the nurse that would most likely foster a therapeutic relationship between the nurse and the client who tries to manipulate people is:"
CHOICES
( X ) a.) Strictness.
( X ) b.) Sympathy.
( X ) c.) Aloofness.
( O ) d.) Consistency.
RATIONALE: It is most important that the nurse maintain a consistent approach when dealing with the client who manipulates others. The nurse should set limits on the client's behavior then consistently enforce these limits to help prevent manipulation. Strictness for its own sake is not appropriate with this client. Sympathy may feed into the client's manipulation. Aloofness will not help establish a therapeutic relationship. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 566 _ about (MC)
QUESTION: "After the client has been on the psychiatric unit for a few days, the nurses notice that he uses his shortness and unattractiveness as an excuse for not attending various social functions, such as the weekly dance. Which of the following interventions would be best to undertake first to deal with the client's avoidance of social functions?"
CHOICES
( X ) a.) Tell the client he will need a better excuse than his appearance for not participating.
( X ) b.) Explain to the client that everyone's cooperation is necessary to make the program a success.
( O ) c.) Confront the client supportively with the fact that he is using his appearance as an excuse to avoid socializing.
( X ) d.) Insist that the client come up with some alternative ways to spend the time when he should be socializing.
RATIONALE: The client needs to be confronted supportively concerning his behavior to learn what is expected of him and how to achieve what is expected. An intervention that indicates the client needs a better excuse than he is using to avoid a social function encourages the use of excuses and belittles the client. The client is unlikely to cooperate when he is told that he should try to make a social event successful. Having the client use an activity other than the one he has planned avoids dealing with a problem and is not a good first action. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 567 _ about (MC)
QUESTION: "Which of the following medications is most likely to be prescribed for the client during withdrawal from alcohol to provide sedation and to ease some of the anxiety and discomfort of the withdrawal process?"
CHOICES
( X ) a.) Paraldehyde (Paral).
( O ) b.) Lorazepam (Ativan).
( X ) c.) Phenytoin sodium (Dilantin).
( X ) d.) Temazepam (Restoril).
RATIONALE: Antianxiety agents such as lorazepam (Ativan) and chlordiazepoxide (Librium) are commonly used to ease symptoms during alcohol withdrawal. Paraldehyde (Paral) is used primarily for its hypnotic and sedative effects. The anticonvulsant phenytoin sodium (Dilantin) does not relieve anxiety. Temazepam (Restoril) is a sedative-hypnotic not used for alcohol withdrawal. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 568 _ about (MC)
QUESTION: "A hospitalized client craves a drink while withdrawing from alcohol. Which of the following measures is the best way to help him resist the urge to drink?"
CHOICES
( X ) a.) A locked-door policy.
( X ) b.) A routine search of visitors.
( X ) c.) One-to-one supervision by the staff.
( O ) d.) Support from other alcoholic clients.
RATIONALE: Group support has proved more successful than individual attention from the staff in influencing positive behavior in alcoholics. Locked doors do not help clients change behavior or develop their own controls. Searching visitors is impractical and externally oriented. One-to-one supervision by staff is impractical and not as effective as a support group. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 569 _ about (MC)
QUESTION: "The nurse is teaching a client about the disease concept of alcoholism. Which of the following client statements indicates that the client understands the nurse's teaching?"
CHOICES
( O ) a.) "Now that I know I have this disease, it's up to me to decide if I'm going to take that drink."
( X ) b.) "I can't help it if I drink. I have an illness."
( X ) c.) "All of my relatives have problems with alcohol, but I' m not as bad as they are."
( X ) d.) "My children won't be affected by my drinking because I've quit."
RATIONALE: The development of alcoholism is influenced by biologic, sociocultural, and environmental factors. The biologic theories of alcoholism clearly identify genetic factors as a major influence on the development of alcoholism in some people. The disease concept of alcoholism permits the individual with the disease to not feel guilty about causing the illness. However, the responsibility of using alcohol is still up to the individual, who alone decides whether or not to take that drink of alcohol. This statement reflects using the disease of alcoholism as an excuse to drink and as a way to avoid responsibility for taking that drink. This statement reflects ongoing denial about alcoholism. Children of alcoholic parents are more likely to become alcoholics than are the children of nonalcoholic parents, even if raised in an alcohol-free environment. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 570 _ about (MC)
QUESTION: "A client is beginning to participate in the alcohol treatment program. Which nursing approach would be most effective in decreasing his denial about his alcoholism?"
CHOICES
( X ) a.) Give him reading materials about the disease of alcoholism.
( O ) b.) Point out concrete problems that are a direct consequence of his alcoholism.
( X ) c.) Explain the physiologic effects of alcohol on the body.
( X ) d.) Teach him assertiveness techniques.
RATIONALE: The nurse would discuss concrete problems that are directly due to the client's alcoholism to confront him, increase his awareness of how alcohol has gotten him into trouble, and help break through his denial. Providing the client with reading material about the disease of alcoholism is helpful, but not as effective as discussing the effects of alcohol on the client's life. Explaining the physiologic effects of alcohol will not help break through the client's denial. Teaching assertiveness techniques may be an important intervention for the client in the later stages of treatment but is not effective in decreasing denial. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 571 _ about (MC)
QUESTION: "A client with alcoholism is started on a regimen of disulfiram (Antabuse). A valuable and expected result of successful disulfiram therapy is that it:"
CHOICES
( X ) a.) Decreases the need for alcohol.
( O ) b.) Acts to deter alcohol consumption.
( X ) c.) Improves the alcoholic's ability to drink limited amounts of alcohol.
( X ) d.) Creates a nerve block so that the effects of alcohol are not felt.
RATIONALE: Disulfiram (Antabuse) helps curb the impulsiveness of the problem drinker because disulfiram blocks the breakdown of alcohol in the blood, which produces marked discomfort such as throbbing headache, flushing, and nausea and vomiting. Disulfiram does not decrease cravings for alcohol. No substance can improve the alcoholic's ability to drink moderately. Disulfiram does not block the effects of alcohol, unlike naloxone (Narcan) which blocks the effects of opioid drugs and can be helpful in the treatment of narcotics addicts. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 572 _ about (MC)
QUESTION: "The client in an outpatient alcohol treatment program states to the nurse, "Why do we need to talk about relapse? I know I'll never drink again." Which of the following responses by the nurse is best?"
CHOICES
( O ) a.) "Anyone can slip. Relapse commonly occurs during the first few months after a treatment program."
( X ) b.) "Relapse prevention is important in follow-up care."
( X ) c.) "It's important to talk about relapse prevention because your recovery has only begun."
( X ) d.) "If you don't continue with follow-up care, you won't hear about relapse prevention."
RATIONALE: The client's statement "I know I'll never drink again" reflects overconfidence, one of the symptoms of relapse. The nurse reminds the client that anyone can slip, that anyone is vulnerable to start drinking again, and that relapse often occurs during the first few months after treatment. This statement is true but is not complete information to give to the client. This statement is true but does not provide any useful rationale for understanding relapse. This statement is not helpful because it does not provide the client with any information about relapse. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 573 _ about (MC)
QUESTION: "For the client experiencing alcohol withdrawal delirium, which of the following physician orders should the nurse question?"
CHOICES
( X ) a.) Lorazepam (Ativan), 2 mg PO every 4 hours prn, for relief of withdrawal symptoms.
( X ) b.) Chlordiazepoxide (Librium), 50 mg PO every 4 hours prn, for agitation.
( O ) c.) Chlorpromazine (Thorazine), 100 mg PO every 4 hours prn, for agitation.
( X ) d.) Thiamine, 100 mg IM daily for 3 days.
RATIONALE: The nurse should question the order for chlorpromazine (Thorazine), 100 mg PO every 4 hours prn, for agitation. Chlorpromazine is a major tranquilizer and antipsychotic that decreases the seizure threshold. During alcohol withdrawal, central nervous system irritability is present, and seizures can occur. The nurse would question this drug order because of the increased risk of seizure. Lorazepam (Ativan), 2 mg PO every 4 hours prn, is an appropriate order because lorazepam is a benzodiazepine used to ease the symptoms of withdrawal from alcohol. Chlordiazepoxide (Librium), 50 mg PO every 4 hours prn, for agitation is an appropriate order because chlordiazepoxide is a benzodiazepine used to ease the symptoms of withdrawal from alcohol. Thiamine, 100 mg IM daily for 3 days, is appropriate and is used to prevent neurologic consequences in the client with chronic alcoholism. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 574 _ about (MC)
QUESTION: "When developing a one-to-one relationship with the client who is withdrawing from alcohol after she is physiologically stable, the nurse should use the first meeting to determine the client's:"
CHOICES
( O ) a.) Healthy coping mechanisms.
( X ) b.) Most probable reasons for alcohol abuse.
( X ) c.) Knowledge about Alcoholics Anonymous.
( X ) d.) Childhood experiences that predispose to alcoholism.
RATIONALE: In early one-to-one helping relationships with this client, focusing on the positive aspects and on healthy coping mechanisms likely would help increase the client's self-esteem. Seeking out reasons for alcohol abuse describes a more traditional mental health approach that has not proved successful with alcoholics. An alcoholic should have a good understanding of Alcoholics Anonymous, but this should not be the focus in early meetings with this client. Delving into childhood experiences is another traditional mental health therapy that is not successful with alcoholics. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 575 _ about (MC)
QUESTION: "The client's husband tells the nurse that he drinks heavily in the evenings and would like to stop. The nurse suggests that he attend Alcoholics Anonymous, but he says, "I went to one men's meeting and all they did was swear and brag about how drunk they got." Which of the following responses would be best for the nurse to make?"
CHOICES
( X ) a.) "That's too bad. I can see how you might have been turned off by the experience."
( X ) b.) "Not everyone finds Alcoholics Anonymous helpful. There are other therapies available."
( O ) c.) "The Alcoholics Anonymous meetings vary from group to group. Have you thought about attending another group?"
( X ) d.) "If you really want to stop your drinking, you would go back to Alcoholics Anonymous whether you liked it or not."
RATIONALE: It would be best for the nurse to support Alcoholics Anonymous and encourage him not to judge the group on the basis of one meeting. Offering sympathy and making judgments about the meeting are not recommended. Because this is the first meeting with the man, it would be inappropriate to suggest that he give up on Alcoholics Anonymous and look at other therapies. A judgmental, accusatory statement will not be supportive or helpful. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 576 _ about (MC)
QUESTION: "A client is brought to the hospital's emergency department by a friend, who states, "I guess he had some bad junk (heroin) today." In assessing the client, the nurse would likely find which of the following symptoms?"
CHOICES
( X ) a.) Increased heart rate, dilated pupils, and fever.
( X ) b.) Tremulousness, impaired coordination, increased blood pressure, and ruddy complexion.
( O ) c.) Decreased respirations, constricted pupils, and pallor.
( X ) d.) Eye irritation, tinnitus, and irritation of nasal and oral mucosa.
RATIONALE: Common signs of heroin overdose are respiratory depression, pale or cyanotic skin and lips, pinpoint pupils, shock, cardiac dysrhythmias, and convulsions. Death may occur from respiratory depression and pulmonary edema. Increased heart rate, dilated pupils, and increased temperature may indicate stimulant abuse. Tremulousness, impaired coordination, increased blood pressure, and a ruddy complexion may indicate alcohol intoxication. Eye irritation, double vision, tinnitus, and irritated mucous membranes could indicate inhalant intoxication. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 577 _ about (MC)
QUESTION: "A client has numerous complaints of discomfort while abstaining from heroin. Which of the following nursing orders on the client's care plan would be the least advisable and effective?"
CHOICES
( X ) a.) Be empathetic but firm.
( O ) b.) Promise to eliminate the client's discomfort.
( X ) c.) Prepare the client in advance for minor discomforts that might occur.
( X ) d.) Inform the client of alternative methods, such as warm baths, for dealing with aches and pains.
RATIONALE: It would be least desirable for the nurse to promise to eliminate the client's discomfort during withdrawal because it is not possible for the nurse to fulfill this promise. Better courses of action for this client include being empathetic but firm to decrease attempts at manipulation. To decrease anxiety and fear about withdrawal symptoms, it is important to prepare the client in advance for the discomfort that likely will occur as heroin is withdrawn. Explain that alternative methods, such as warm baths, can help with discomfort and are useful in easing muscle aches and cramps experienced during withdrawal. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 578 _ about (MC)
QUESTION: "The client is being tested for the human immunodeficiency virus (HIV). The nursing staff is concerned about possible HIV exposure among other clients on the unit and among themselves. Which of the following precautionary measures is the least important?"
CHOICES
( X ) a.) Strict handwashing procedures.
( O ) b.) A private room for the client.
( X ) c.) Wearing gloves when handling body fluids.
( X ) d.) Increased caution in disposing of needles and syringes.
RATIONALE: A private room is not indicated unless necessitated by the presence of another infection. Handwashing is the foundation of infection control. Protection from HIV infection includes wearing gloves before touching mucous membranes and blood or other body fluids. Needles should not be broken or recapped; rather, the syringe and needle should be placed in a puncture-resistant container. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control
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--> QUESTION NUMBER _ 579 _ about (MC)
QUESTION: "While the client is in chemical dependency rehabilitation, which nursing intervention would be least appropriate?"
CHOICES
( O ) a.) Call a Narcotics Anonymous group for the client to tell them to expect the client after discharge.
( X ) b.) Enforce unit policies.
( X ) c.) Confront the client's inappropriate behaviors.
( X ) d.) Help the client to express feelings.
RATIONALE: Calling Narcotics Anonymous to tell them to expect the client is inappropriate and unnecessary because it increases the client's dependency on the nurse. It is the client's responsibility to make arrangements for attending meetings. Enforcing unit policies is an important component in establishing a therapeutic milieu. Confronting inappropriate behaviors like manipulation and use of defense mechanisms such as projection are part of the nurse's role in drug rehabilitation. Helping the client to express feelings appropriately through the use of assertiveness techniques teaches the client appropriate interpersonal skills. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 580 _ about (MC)
QUESTION: "By which of the following symptoms could the client probably have been identified as a chronic user of barbiturates in the days before her hospitalization?"
CHOICES
( X ) a.) Drooling, fainting, and illusions.
( O ) b.) Sluggishness, ataxia, and irritability.
( X ) c.) Diaphoresis, twitching, and sneezing.
( X ) d.) Suspiciousness, tachycardia, and edema.
RATIONALE: Typical signs and symptoms of barbiturate abuse include sluggishness, difficulty walking, and irritability. Judgment and understanding are impaired, and speech is slurred and confused. The client acts drunk as from alcohol but does not have the odor of alcohol on her breath. These are not effects of barbiturate use. These are not effects of barbiturate use. These are not effects of barbiturate use. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 581 _ about (MC)
QUESTION: "After a dose-response test, the client with an overdose of barbiturates receives pentobarbital sodium (Nembutal) at a nonintoxicating maintenance level for 2 days and at decreasing doses thereafter. This regimen is prescribed primarily to help prevent possibly fatal:"
CHOICES
( X ) a.) Psychosis.
( O ) b.) Convulsions.
( X ) c.) Hypotension.
( X ) d.) Hypothermia.
RATIONALE: Generalized convulsions may occur on the second or third day of withdrawal from barbiturates. Without treatment, the convulsions may be fatal. Psychosis is a possibility but is not fatal and will not be prevented by the pentobarbital sodium regimen. Postural hypotension is possible but is unlikely to be fatal; it is also not treatable by the pentobarbital sodium regimen. Hyperthermia, rather than hypothermia, occurs during withdrawal. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 582 _ about (MC)
QUESTION: "The nurse is working in a community mental health center. A client with an Axis I diagnosis of Anxiolytic Withdrawal is prescribed prazepam (Centrax) in daily decreasing doses for 3 weeks. She has been taking Centrax for 3 days. The client had been dependent on diazepam (Valium), which she had been taking daily for the past 8 months at a dose of 60 mg. The client states she feels shaky, is having problems sleeping, and does not want to continue with Centrax. She asks the nurse if she can stop taking the Centrax now. The nurse's best response is:"
CHOICES
( O ) a.) "You need to continue the Centrax as prescribed to ensure a slow and safe withdrawal."
( X ) b.) "Because your symptoms of withdrawal are minimal, you can take the Centrax when you feel you need it."
( X ) c.) "You can discontinue the Centrax because the worse symptoms of withdrawal are over."
( X ) d.) "I recommend one dose of Centrax at bedtime to help you sleep."
RATIONALE: The nurse instructs the client to continue taking prazepam (Centrax) as prescribed to ensure a safe, slow tapering withdrawal from diazepam (Valium). This reflects poor nursing judgment as the client needs to follow the tapering schedule to ensure a safe withdrawal from benzodiazepine dependence. This reflects poor nursing judgment as the client needs to follow the tapering schedule to ensure a safe withdrawal from benzodiazepine dependence. This reflects poor nursing judgment as the client needs to follow the tapering schedule to ensure a safe withdrawal from benzodiazepine dependence. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 583 _ about (MC)
QUESTION: "It is desirable for group members to use functional roles to obtain the most benefit from the group. In which of the following examples from a nurse-led group for compulsive overeaters is a group role (versus an individual role) being used by one of the members? The member:"
CHOICES
( X ) a.) Shows the group the latest pictures of her child.
( X ) b.) Insists that everyone try her favorite reducing diet.
( X ) c.) Makes quiet comments to the person sitting next to her.
( O ) d.) Proposes an alternative task to keep from thinking about food.
RATIONALE: A member of the group is assuming a functional role when she proposes an alternate task to keep from thinking about food. She acts in the role of a contributor to the group. Showing pictures of children is an example of individual role behavior that is irrelevant to the group task. Showing pictures of one's child in a group is an example of a blocker. Insisting that everyone try a favorite reducing diet is an example of individual role behavior that is irrelevant to the group task. The person who insists that everyone try her recipe is a special-interest pleader. Making comments to another group member is an example of individual role behavior that is irrelevant to the group task. The person making comments to another group member is withdrawing from the group. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 584 _ about (MC)
QUESTION: "An adolescent client is admitted to the psychiatric unit for rapid weight loss associated with anorexia nervosa. She is 5 feet, 2 inches tall, and weighs 70 pounds. Physical manifestations most likely to be found during nursing assessment include:"
CHOICES
( X ) a.) Tachycardia, hypertension, and hyperthyroidism.
( X ) b.) Tachycardia, hypertension, and iron-deficiency anemia.
( X ) c.) Hypotension, elevated serum potassium level, and vitamin C deficiency.
( O ) d.) Bradycardia, hypotension, and cold sensitivity.
RATIONALE: Bradycardia, hypotension, and cold sensitivity reflect the slowed metabolism that occurs with severe weight loss. Tachycardia and hypertension reflect increased metabolic rate, which is inconsistent with anorexia nervosa. Hyperthyroidism is not typical in anorexic clients. Tachycardia and hypertension reflect increased metabolic rate, which is inconsistent with anorexia nervosa. Anemia may occur but is not a hallmark of the disease. Hypotension may occur, but elevated serum potassium is atypical with anorexia. Vitamin C deficiency may occur but it is not a hallmark symptom of the disorder. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 585 _ about (MC)
QUESTION: "An adolescent is hospitalized with anorexia nervosa. The nurse enters the client's room and finds her doing sit-ups. What would be the nurse's best approach?"
CHOICES
( X ) a.) Wait until she finishes and ask her why she feels the need to exercise.
( X ) b.) Remind her that if she loses weight, she will lose privileges.
( O ) c.) Ask her to stop doing the sit-ups and direct her to a quiet activity.
( X ) d.) Leave the room and allow her to exercise in private.
RATIONALE: The primary goal with severe anorexia is to promote weight gain through behavior modification. This involves actively monitoring and interrupting undesirable behaviors, even against the client's protests. Waiting for the client to finish exercising may be polite but exacerbates weight loss as more calories are burned. Threatening future loss of privileges does not motivate a client who is in the middle of a compulsion. Active intervention is required to prevent continued weight loss. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 586 _ about (MC)
QUESTION: "The 17-year-old client with an Axis I diagnosis of bulimia nervosa is hospitalized on the inpatient unit. The client weighs 5 pounds less than her ideal weight for her height. She tells the nurse, "I don't have a problem. I'm not really underweight." The nurse's best response is:"
CHOICES
( X ) a.) "Your parents told the physician that you do have a problem."
( O ) b.) "Even though your weight is almost ideal for your height, purging and using laxatives are harmful to your body."
( X ) c.) "We'll find out if you do have a problem while you're here."
( X ) d.) "It's often difficult to acknowledge our imperfections."
RATIONALE: The nurse acknowledges the client's perception and does not challenge the client and her expression of feeling. Telling the client that purging and using laxatives are harmful behaviors is honest and accurate information. This statement places blame for the client's hospitalization on the parents, which may foster angry feelings in the client. This statement is trite and instills blame and guilt toward the client for not being perfect. It also belittles the client. Suggesting that the client has imperfections is inappropriate and challenges the client to defend her beliefs. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 587 _ about (MC)
QUESTION: "A client is brought to the hospital emergency department by his brother. The client is perspiring profusely, breathing rapidly, and complaining of dizziness and palpitations. Problems of a cardiovascular nature are ruled out. The client's diagnosis is tentatively listed as Panic Attack. The emergency room nurse observes that the client is hyperventilating. Which of the following measures would be best to try first to ease the symptoms caused by hyperventilation?"
CHOICES
( O ) a.) Have the client breathe into a paper bag.
( X ) b.) Instruct the client to put his head between his knees.
( X ) c.) Give the client a low concentration of oxygen by nasal cannula.
( X ) d.) Tell the client to take several deep, slow breaths and exhale normally.
RATIONALE: The best way to ease symptoms caused by hyperventilation is to have the client breathe into a paper bag. This helps to raise CO 2 which encourages deeper, slower breathing. Having the client put his head between his knees will not alleviate symptoms of hyperventilation. Giving him low concentrations of oxygen will not alleviate symptoms of hyperventilation. Having him take deep, slow breaths and exhale normally will not alleviate symptoms of hyperventilation. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 588 _ about (MC)
QUESTION: "Which of the following nursing actions would be inappropriate on the client's admission to the unit with panic attack?"
CHOICES
( X ) a.) Support the client's attempts to discuss feelings.
( X ) b.) Respect the client's personal space.
( X ) c.) Reassure the client of his safety.
( O ) d.) Confront the client's dysfunctional coping behaviors.
RATIONALE: Confronting dysfunctional coping behaviors or defense mechanisms will most likely be viewed as a threat and will increase anxiety. Supporting the client in his attempts to discuss feelings conveys empathy and is a therapeutic response. Respecting personal space demonstrates caring and helps to prevent escalation of anxiety. Reassuring him about his safety promotes a therapeutic nurse-client relationship and prevents escalation of anxiety. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 589 _ about (MC)
QUESTION: "During a conversation with the client, the nurse observes the client shaking his leg and tapping his fingers on the table next to him. The nurse's best statement is:"
CHOICES
( X ) a.) "I see that you're anxious. I'll be back later when you're calmer."
( O ) b.) "I noticed that your leg is shaking and you're tapping your fingers on the table. How are you feeling now?"
( X ) c.) "I'll get you something to help you feel less anxious."
( X ) d.) "I know that you feel anxious. Let's discuss something more pleasant."
RATIONALE: The nurse helps the client to recognize that he is feeling anxious by pointing out his behaviors to him. The nurse then attempts to help the client recognize his anxiety and describe his feelings to help him connect behaviors with feelings. Telling the client that she will be back later abandons the client and may increase his anxiety. Offering the client something to help him feel less anxious is plausible, however, the nurse should first attempt to reduce the client's anxiety through nonpharmacologic means. Changing the subject will not help the client deal with his feelings. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 590 _ about (MC)
QUESTION: "The client with an Axis I diagnosis of posttraumatic stress disorder tells the nurse he wishes that he had been on the airplane that crashed and killed his wife and children a month ago. The nurse assesses the client's statement to be indicative of:"
CHOICES
( X ) a.) Suicidal ideation.
( O ) b.) Survivor guilt.
( X ) c.) Dysfunctional grieving.
( X ) d.) Numbing of responsiveness.
RATIONALE: With posttraumatic stress disorder, the client experiences survivor guilt or feelings of guilt related to being alive. The client's statement does not indicate suicidal ideation. Dysfunctional grieving is inaccurate because the accident occurred only a month ago. Numbing of responsiveness pertains to having a restricted affect, a limitation in the range of feelings, a feeling of detachment from others and the external world, and hopelessness or lack of expectations about the future. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 591 _ about (MC)
QUESTION: "A client with posttraumatic stress disorder states, "You don't know what I've been through. What can you do?" The nurse's best response is:"
CHOICES
( X ) a.) "I need to refer you to a survivors' group where you'll feel more comfortable."
( X ) b.) "Perhaps you'll feel better if you can become interested in a hobby once again."
( X ) c.) "I'd like to help you if you'll let me."
( O ) d.) "I haven't been through what you have, but I'll be better able to understand if you tell me more about it."
RATIONALE: The nurse is nonjudgmental, supportive, and conveys honesty and empathy to the client. Telling the client he'll feel more comfortable in a survivors' group dismisses the client. However, a survivors' group may be needed later. Stating that the client should become interested in a hobby dismisses his feelings and is not helpful. This statement implies that the client is not being cooperative; it may alienate him. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 592 _ about (MC)
QUESTION: "A week ago, a tornado destroyed the client's home and seriously injured her husband. The client has been walking around the hospital in a daze without any outward display of emotions. The client is being admitted to the stress unit with the diagnosis of Acute Stress Disorder. The client tells the nurse in a matter-of-fact manner that her husband is paraplegic, "but that's better than total paralysis." Which protective mechanism is the client exhibiting?"
CHOICES
( X ) a.) Suppression.
( X ) b.) Rationalization.
( X ) c.) Denial.
( O ) d.) Intellectualization.
RATIONALE: The client is exhibiting intellectualization, which is using logical explanations without feelings or an affective component. Suppression is the voluntary exclusion from awareness of feelings, ideas, or situations that are anxiety provoking. Rationalization is an attempt to make or prove that one's feelings or behaviors are justifiable. Denial is an unconscious refusal to admit an unacceptable idea or behavior. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 593 _ about (MC)
QUESTION: "A decision is made to not hospitalize a client with obsessive-compulsive disorder. Of the following abilities the client has demonstrated, the one that probably most influenced the decision not to hospitalize him is his ability to:"
CHOICES
( X ) a.) Hold a job.
( X ) b.) Relate to his peers.
( O ) c.) Perform activities of daily living.
( X ) d.) Behave in an outwardly normal manner.
RATIONALE: A client able to take care of his basic nutritional needs is probably not sufficiently incapacitated by his illness to require hospitalization. The client's ability to hold a job may be considered in making the decision but is a not valid criterion for hospitalization. The client's ability to relate to his peers may be considered in making the decision but is not valid criterion for hospitalization. The ability to behave normally is of lesser importance in this decision, depending on the client's family's or significant others' tolerance of the behavior. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 594 _ about (MC)
QUESTION: "The client with obsessive-compulsive disorder eats slowly and is always the last to finish lunch, which makes it difficult for the group to start a 1:00 PM outing. Which of the following approaches would be the best plan of action for this problem?"
CHOICES
( X ) a.) Change the time of the outing to accommodate the client.
( O ) b.) Arrange for the client to start eating earlier than the others.
( X ) c.) Plan to go without the client so that he will have ample time for his lunch.
( X ) d.) Inform the client that he will have to eat faster so that the group can leave on time.
RATIONALE: Letting the client eat earlier meets his needs for more time and also the group's need to depart for the outing on time. It also protects the client from being resented by others and lets him be included in the group activity. Changing the time of an activity to meet one client's needs is undesirable and may be impractical as well. Going on the outing without the client will result in decreasing the client's self-esteem and increasing anxiety and the need to maintain his symptoms. This statement blames the client and results in increased anxiety and guilt and further reinforces the need for compulsive behavior. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 595 _ about (MC)
QUESTION: "A client reports that before he leaves home to go anywhere, he counts the money in his wallet as many as 12 times. The best explanation for the client's motives when performing this particular ritual is that he is attempting to:"
CHOICES
( X ) a.) Channel excessive sexual energy into an appropriate habit.
( X ) b.) Compensate for not having had enough money to spend as a child.
( X ) c.) Avoid the embarrassment of having a shortage of funds on hand.
( O ) d.) Channel emotions unacceptable to him with an acceptable activity.
RATIONALE: The dynamics of compulsive activity involve a defense against anxiety by persistently doing something to bind or reduce anxiety. This behavior occurs each time threatening thoughts occur. Channeling excessive sexual energy into an appropriate habit is an incorrect understanding of the dynamics of the disorder. Judgment that the client counts money repeatedly to compensate for not having had enough money to spend as a child is based on insufficient data and represents an oversimplification of the client's problem. Judgment that the client counts money repeatedly to avoid the embarrassment of running short is based on insufficient data and represents an oversimplification of the client's problem. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 596 _ about (MC)
QUESTION: "Which of the following actions would be best for the nurse to take when observing the client in a ritualistic pattern of behavior?"
CHOICES
( X ) a.) Isolate the client so that he will not disturb others.
( X ) b.) Observe the client closely for marked changes in behavior.
( X ) c.) Remind the client that he can control his behavior if he wishes.
( O ) d.) Allow the client to continue so that he will not become more anxious.
RATIONALE: It is best to accept compulsive behavior in a comparatively permissive manner. The client may become increasingly anxious if he is denied the ritualistic activity. Isolating the client is inappropriate because it will have no effect on the behavior and will decrease the client's self-esteem. Observing for marked changes in behavior is unwarranted as this is unlikely. Reminding him that he can control his behavior if he wishes is inappropriate in this situation, because the action is needed to control anxiety. The nurse works with the client to find alternative anxiety management methods that will result in a decrease in ritualistic behavior. Interrupting the behavior will increase anxiety. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 597 _ about (MC)
QUESTION: "Which of the following qualities is most important for the nurse interacting with obsessive-compulsive clients?"
CHOICES
( O ) a.) Patience.
( X ) b.) Compassion.
( X ) c.) Friendliness.
( X ) d.) Self-confidence.
RATIONALE: The obsessive-compulsive client cannot be hurried. Therefore, patience is the most important quality to demonstrate. Unless nurses are patient, they can easily become frustrated, upset, or angry. Compassion is certainly a desirable quality but it will not be enough when caring for the obsessive-compulsive client. Friendliness is useful; however, it is not necessarily therapeutic in nature. Self-confidence may be desirable to some degree in caring for a client with an obsessive-compulsive disorder, however, patience will be required most frequently. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 598 _ about (MC)
QUESTION: "The client has been taking clomipramine (Anafranil) for his obsessive-compulsive disorder. He tells the nurse, "I'm not really better, and I've been taking the medication faithfully for the past 3 days just like it says on this prescription bottle." Which of the following actions would the nurse do first?"
CHOICES
( O ) a.) Tell the client to continue taking the medication as prescribed because it takes 2 to 4 weeks for a full therapeutic effect.
( X ) b.) Tell the client to stop taking the medication and to call the physician.
( X ) c.) Encourage the client to double the dose of his medication.
( X ) d.) Ask the client if he has resumed smoking cigarettes.
RATIONALE: It takes 2 to 4 weeks of clomipramine (Anafranil) therapy to derive full therapeutic effect for clients with obsessive-compulsive disorder. This reflects poor nursing judgment as it is too early to tell if the medication will be effective. This reflects poor nursing judgment and may be harmful. Asking the client if he has resumed smoking is appropriate because smoking increases the metabolism of clomipramine, necessitating a dosage adjustment to achieve therapeutic effect. It would not be the first statement to make to this client though. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 599 _ about (MC)
QUESTION: "Which of the following methods of treatment would initially be least helpful to a client with obsessive-compulsive disorder?"
CHOICES
( X ) a.) Relaxation exercises.
( O ) b.) Meditation.
( X ) c.) Listening to soothing music.
( X ) d.) Exposure therapy.
RATIONALE: Meditation would not be helpful for the client because of increased anxiety, which interferes with concentration, thinking, and focusing. After obsessions and compulsions decrease, the client may find meditation helpful and calming. Relaxation exercises are potentially therapeutic for a client with obsessive-compulsive disorder because they decrease anxiety by relieving muscle tension. Listening to soothing music promotes relaxation and decreases anxiety. Exposure therapy is potentially therapeutic and beneficial because systematic exposure and response prevention blocks the compulsive behavior; the client learns to manage increased anxiety with relaxation techniques. This results in decreased anxiety when the ritual is not performed. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 600 _ about (MC)
QUESTION: "The client with conversion disorder has a paralyzed arm. While assisting the client with self-care, which of the following approaches would the nurse employ? "
CHOICES
( X ) a.) Use a strong confrontational approach.
( X ) b.) Interact minimally with the client.
( O ) c.) Demonstrate a matter-of-fact, caring attitude.
( X ) d.) Ignore the client's negative comments.
RATIONALE: The nurse uses a matter-of-fact, caring approach to decrease secondary gain and to decrease focusing on physical symptoms. Using a strong confrontational approach may anger the client, reinforcing the need for physical symptoms. Minimally interacting with the client is not therapeutic and ignores the client's needs. Ignoring the client's negative comments is counterproductive because the client with a somatoform disorder like conversion disorder needs to identify and describe feelings, even negative ones, to decrease the need for bodily symptoms. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 601 _ about (MC)
QUESTION: "A client is admitted to the psychiatric hospital for evaluation after numerous incidents of threatening, angry outbursts and two episodes of hitting a coworker at the grocery store where he works. The client is very anxious and tells the nurse who admits him, "I didn't mean to hit him. He made me so mad that I just couldn't help it. I hope I don't hit anyone here." Which of the following responses by the nurse is best?"
CHOICES
( O ) a.) "It sounds like you were angry. When you feel angry here, talk to the staff about it instead of hitting."
( X ) b.) "You'd better not hit anyone here, even if you do get mad."
( X ) c.) "Tell me more about what happened."
( X ) d.) "I'm sure you didn't mean to hit him and that it won't happen here."
RATIONALE: Describing acceptable behavior to the client focuses on the immediate problem. Threatening statements do not elicit further information and are not therapeutic. Asking the client to explain what happened is a therapeutic statement likely to elicit assessment data, but it is less focused on the client's immediate problem. Providing false reassurance is never therapeutic, may decrease the client's trust, and does nothing to help the client manage feelings. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 602 _ about (MC)
QUESTION: "The client in a psychiatric hospital for evaluation after a number of threatening, angry outbursts rushes out of the day room where he has been watching television with other clients. He is hyperventilating, flushed, and his fists are clenched. He states to the nurse, "That bastard! He's just like Tom. I almost hit him." Which of the following would be the nurse's best response?"
CHOICES
( O ) a.) "You're angry and you did well to leave the situation. Let's walk up and down the hall while you tell me about it."
( X ) b.) "Even if you're angry, you can't use that language here."
( X ) c.) "I'm glad you left the situation. Why don't you go to your room and calm down. I'll come in soon to talk."
( X ) d.) "I can see you're angry. Let me get you some Ativan to help you calm down. Then we'll talk about what happened."
RATIONALE: The nurse acknowledges and labels the client's emotion and acknowledges his appropriate behavior. Recognizing the client's physiologic arousal, the nurse suggests an activity and stays with him. Setting limits on the client's language does not acknowledge his control and does not help the client manage his anxiety. The client needs to engage in physical activity to decrease muscle tension and anxiety. Offering the client medication suggests that he cannot control his behavior. Medication would be used only if other interventions failed to reduce the anxiety level. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 603 _ about (MC)
QUESTION: "In talking with his nurse about discharge from a psychiatric hospital, the client says, "It's been easy not to get mad and hit people here because the staff won't let me. It's not the same at work." What would be the nurse's most effective response?"
CHOICES
( X ) a.) "We have helped, but you're the one who decided not to hit when you were angry. You can do that at work too."
( X ) b.) "Lots of people feel this way. You're just worried about leaving the hospital. You've learned so much that you won't have any problems at work."
( O ) c.) "You sound worried about going back to work. The things you've learned here can help at work too. Let's talk about what you learned and how you can use it."
( X ) d.) "It's hard to leave the hospital, but you're better and need to get back to work. You'll be okay, I know."
RATIONALE: The nurse acknowledges the client's concern and provides an opportunity to review his progress and to prepare for the work situation. This statement is therapeutic but does not review the client's progress or prepare him for the work situation. Providing false reassurance will not help the client get over his feelings of anxiety. This is an example of false reassurance. It dismisses the client's concerns and will not help him get over his feelings of anxiety. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 604 _ about (MC)
QUESTION: "The client is admitted to the hospital because of threatening, aggressive behavior toward his family. Which of the following factors is most important for the nurse to consider when assessing the angry client's potential for violence?"
CHOICES
( X ) a.) The time of day and level of activity on the unit.
( X ) b.) The attitude of the staff toward the angry client.
( X ) c.) The staff-to-client ratio.
( O ) d.) The client's past history of violent behavior.
RATIONALE: The client's past history of violent behavior is the most accurate predictive factor. Violent behavior is more likely when there is a demand for high activity; however, this is not the strongest risk factor. There is an increased chance of violent behavior when the staff feels hopeless about a client because the client can recognize their feelings and may be unwilling to learn adaptive coping. However, this is not the strongest risk factor. With inadequate staffing, the chance for violent behavior increases because timely intervention before escalation of agitation may not be possible. However, this is not the strongest risk factor. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 605 _ about (MC)
QUESTION: "A client's face is flushed. He is swearing, yelling, and pushing chairs around the day room of a mental health center. The nurse judges the client to be in which phase of the assault cycle?"
CHOICES
( X ) a.) Triggering.
( O ) b.) Escalation.
( X ) c.) Crisis.
( X ) d.) Aggressive.
RATIONALE: The escalation phase of the assault cycle involves agitation, swearing, screaming, demanding, and provocative behaviors with loss of reasoning ability. Some behaviors in the triggering phase involves muscle tension, irritability, restlessness, perspiration, and changes in breathing and voice quality. The crisis phase involves loss of self-control, hitting, scratching, kicking, and throwing things. Aggressive is not a phase of the assault cycle. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 606 _ about (MC)
QUESTION: "Indirect expression of anger is more common than direct expression. Which of the following client behaviors is most likely to be an indirect expression of anger?"
CHOICES
( O ) a.) Responding sarcastically to an invitation to join a unit activity.
( X ) b.) Refusing to take medication.
( X ) c.) Cursing at the physician.
( X ) d.) Shouting at another client.
RATIONALE: Sarcasm is frequently used to express anger indirectly. Refusing medication is a direct expression of anger. Cursing is also a direct expression of anger. Shouting is a more direct expression of angry negative feelings. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 607 _ about (MC)
QUESTION: "A client who has been physically abused by her spouse agrees to meet with the nurse. Before the nurse terminates the meeting with the client, which nursing action is most important?"
CHOICES
( O ) a.) Give the client the telephone numbers of a shelter or a safe house and the crisis line.
( X ) b.) Advise the client to leave her husband.
( X ) c.) Tell the client not to do anything that could upset her husband.
( X ) d.) Ask the client what she could do to de-escalate the situation at home.
RATIONALE: The nurse would provide the client with resources or support systems to turn to when the next battering incident occurs. It is inappropriate to advise the client to leave her husband. The client should not be pushed or coerced into leaving her husband until she is ready. Telling the client not to do anything to upset her husband places blame for the violence on the client. Asking her what she could do to de-escalate the situation at home indirectly confers blame on the client. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 608 _ about (MC)
QUESTION: "As the nurse learns more about the abused client and her family, which of the following characteristics is the nurse least likely to find to be true about the abuser?"
CHOICES
( O ) a.) Between episodes of abuse, he has a warm, empathetic relationship with his wife.
( X ) b.) He grew up in an abusive family.
( X ) c.) He is a college graduate and has a stable work history.
( X ) d.) He abuses alcohol.
RATIONALE: Lack of empathy characterizes relationships in abusive families. It is more likely that the relationship is built around the abuser's need for power and control. A history of family violence and low self-esteem are common among abusers. The idea that only poorly educated, poorly employed men are abusive is a myth. Most alcohol abusers batter their partners, regardless of whether or not they are drinking at the time. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 609 _ about (MC)
QUESTION: "The nurse discusses the abused client and her family in a staff meeting. Which of the following statements made by other staff members is likely to be most helpful to the nurse in developing a treatment plan?"
CHOICES
( X ) a.) "This client sounds like a lot of women I know who don't want to change. You can try family therapy, if the husband will come."
( O ) b.) "Have you thought about suggesting that she attend the group for women in abusive families?"
( X ) c.) "I think she should call the police."
( X ) d.) "Have you thought about calling the client's mother to find out what she knows about the family?"
RATIONALE: Group therapy with women with similar problems may help the client reduce her isolation and sense of shame. The idea that abuse victims do not want to change is inaccurate and leads to feelings of hopelessness among professionals. Calling the police may be an option for the client but is not the most helpful because it does not consider help and treatment for the victim. The victim may need time to reach this decision or option. Contacting other people about the client and family without the client's consent violates confidentiality. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 610 _ about (MC)
QUESTION: "As the nurse develops a treatment plan for an abused client, which of the following factors would be least important to consider?"
CHOICES
( X ) a.) The abuser's refusal to be involved in treatment.
( X ) b.) The client's coping skills.
( X ) c.) The recent promotion of the client's husband.
( O ) d.) The birthday party for the client's child next week.
RATIONALE: Although any event in a family can contribute to an abusive episode, the birthday party is less important to treatment planning than the husband's promotion. The husband's refusal of treatment is an important consideration in treatment planning. The client's coping skills are very important factors to capitalize on when developing a treatment plan. The husband's promotion is a potential major stressor and is an important consideration in developing the treatment plan. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 611 _ about (MC)
QUESTION: "An abused woman tells the nurse that her 8-year-old daughter refuses to go to school because she is afraid her mother will not be home when she returns. Which of the following is the most therapeutic response for the nurse to make?"
CHOICES
( X ) a.) "She must be feeling insecure right now. Let her stay home with you for a few days to reassure her."
( X ) b.) "Children often feel responsible for trouble in the family. Have you talked with her about what she's afraid might happen?"
( X ) c.) "You know she's too young to be home alone after school. If you can't be there, you should find someone else to meet her so she won't be afraid."
( O ) d.) "She's aware of the trouble in the family and is worried about what might happen. Would you like to have her talk to the child therapist here? I think it would be helpful."
RATIONALE: It is important that the nurse address the family problem and include the client in making decisions about her daughter. Allowing the child to remain at home ignores the basic family problem. Asking the client to talk to her daughter is appropriate but is not a sufficient intervention in this situation. Having someone else at home to meet her ignores the basic family problem. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 612 _ about (MC)
QUESTION: "The client, who is dying from acquired immunodeficiency syndrome (AIDS), is admitted to the inpatient psychiatric unit because he attempted suicide. His close friend recently died from AIDS. The client states to the nurse, "What's the use of living? My time is running out." What is the nurse's best response?"
CHOICES
( X ) a.) "Let's talk about making some good use of that time."
( X ) b.) "Don't give up. There could be a cure for AIDS tomorrow."
( O ) c.) "You're in a lot of pain. What are you feeling?"
( X ) d.) "Life is precious and worth living."
RATIONALE: The nurse recognizes the client's pain, hopelessness, and sense of loss related to his condition and the loss of his friend and encourages him to express his feelings. Giving the client permission to talk about his feelings of sadness, loss, and hopelessness and listening to him is an important nursing intervention for the dying client. This statement diverts attention from the content of the client's statements and blocks expression of feelings. "Don't give up" is a type of pep talk that ignores the client's feelings. This statement ignores the client's needs and inhibits his expression of feelings. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 613 _ about (MC)
QUESTION: "One staff member in a psychiatric unit says to the nurse, "Why are we carrying out suicide precautions for someone who is dying? It's pointless and a waste of time." The nurse should:"
CHOICES
( X ) a.) Assign the staff member to other clients.
( X ) b.) Ask the psychiatric clinical nurse specialist to meet with the staff member.
( X ) c.) Agree with the staff member and discontinue suicide precautions.
( O ) d.) Call for a multidisciplinary staff meeting.
RATIONALE: The nurse would call for a multidisciplinary staff meeting because there is a need for staff members to share their feelings of anger, frustration, and grief. Because nurses focus on saving human lives, any feelings of hopelessness regarding a dying client can interfere with the client's care and management. Assigning the staff member to other clients ignores the staff's need to work through feelings. Calling the clinical nurse specialist to deal with the staff member does nothing to help the immediate situation. The psychiatric clinical nurse specialist would be included in the staff meeting to help the entire staff deal with their feelings. Agreeing with the staff member and discontinuing suicide precautions is highly inappropriate. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Management of care
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--> QUESTION NUMBER _ 619 _ about (MC)
QUESTION: "The client with dual diagnoses of major depression and alcohol abuse states, "I only drink when I can't sleep." An initial outcome for this client is that the client will:"
CHOICES
( X ) a.) Describe adaptive methods of coping to induce sleep.
( X ) b.) Verbalize negative effects of alcohol on the body.
( X ) c.) Describe dangerous effects when combining alcohol and antidepressant medication.
( O ) d.) Verbalize the desire to stop drinking alcohol.
RATIONALE: Verbalizing the desire to stop drinking alcohol is an initial outcome that acknowledges alcohol consumption as a problem behavior and leads to further participation in treatment. Describing adaptive methods to use instead of drinking alcohol to induce sleep is an outcome to be reached later in the client's course of treatment. Verbalizing the negative effects of alcohol on the body is a therapeutic behavior but is not specific to helping the client sleep. Describing the dangerous effects of using alcohol with antidepressant medication is a therapeutic behavior but is not specific to helping the client sleep. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 623 _ about (MC)
QUESTION: "The nurse will conduct a psychoeducational group for family members about depression. Which of the following topics would be of little help to the family members?"
CHOICES
( X ) a.) Managing the depressed client at home.
( O ) b.) Drug classifications.
( X ) c.) Support and self-help groups.
( X ) d.) Education about depression.
RATIONALE: Focusing on antidepressant medications would be helpful, but the topic of drug classifications is too general. A topic such as managing the depressed client at home will help family members learn positive techniques for managing day-to-day problems and will promote family cohesiveness. A topic such as receiving support from self-help groups is helpful to family members to reduce feelings of isolation and powerlessness. Educating the family about the illness dispels myths, enlists family cooperation, and promotes adaptive coping skills. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 629 _ about (MC)
QUESTION: "In teaching a client about Alcoholics Anonymous, the nurse states that Alcoholics Anonymous has helped in the rehabilitation of many alcoholics, probably because many people find it easier to change their behavior when they:"
CHOICES
( O ) a.) Have the support of rehabilitated alcoholics.
( X ) b.) Know that rehabilitated alcoholics will sympathize with them.
( X ) c.) Can depend on rehabilitated alcoholics to help them identify personal problems related to alcoholism.
( X ) d.) Realize that rehabilitated alcoholics will help them develop defense mechanisms to cope with their alcoholism.
RATIONALE: Membership in Alcoholics Anonymous is voluntary. Its rehabilitated members are available to support alcoholics, and the understanding and influence of these rehabilitated members often helps alcoholics change their behavior. The role of rehabilitated members does not include sympathizing with others abusing alcohol. The role of rehabilitated members does not include helping others abusing alcohol to identify personal problems. The role of rehabilitated members does not include helping others abusing alcohol to develop defense mechanisms to cope with alcoholism. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 630 _ about (MC)
QUESTION: "A client walks into the mental health clinic and states to the nurse, "I guess I can't make it without my wife. I can't even sleep without her." Which of the following responses by the nurse would be most therapeutic?"
CHOICES
( X ) a.) "Things always look worse before they get better."
( X ) b.) "I'd say that you're not giving yourself a fair chance."
( X ) c.) "I'll ask the doctor for some sleeping pills for you."
( O ) d.) "Tell me more about what you mean when you say you can't make it without your wife."
RATIONALE: The nurse helps the client explore his feelings by expressing interest in knowing more about his problem in order to make an accurate assessment. Cliches minimize the client's feelings and block expression. Statements that make unwarranted judgments about the client block communication and may suggest that he should feel guilty for his feelings. The nurse has not explored the client's feelings or made any assessment. Asking the doctor for sleeping pills reflects poor judgment based on insufficient assessment data. Sleeping pills may be inappropriate and not therapeutic for this client. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 633 _ about (MC)
QUESTION: "During the conversation with the nurse, a victim of physical abuse says, "Let me try to explain why I stay with my husband." Which of the following reasons would the client be least likely to mention?"
CHOICES
( X ) a.) "I'm responsible for keeping my family together."
( O ) b.) "When it's not too bad, the abuse adds spice to our relationship."
( X ) c.) "I love my husband."
( X ) d.) "I'm not sure I could get a job that pays even minimum wage."
RATIONALE: Violence is never acceptable to a victim; this myth condones the use of violence. Often, an episode of battering is followed by a period of pleasant relations between the partners, during which the victim may hope that the violence will never happen again. The victim may stay in the relationship for that reason. Women are conditioned to be responsible for the family's well-being. This is often a motivation for a battered woman to stay in an abusive relationship. The victim believes that she can save the relationship and that her partner will change. Feelings of guilt surrounding issues such as these often influence an abused woman's decisions about staying with her partner. A woman's lack of job skills and financial resources may cause her to stay. Many women are injured or killed when they try to leave in a violent relationship. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 635 _ about (MC)
QUESTION: "During a home visit, the client tells the nurse she's not taking prescribed doses of haloperidol (Haldol) because she's tired of bothering with it and doesn't need it. The nurse's best action is to:"
CHOICES
( X ) a.) Explain the negative effects of skipping the medication.
( O ) b.) Consult with the physician about changing the medication to haloperidol decanoate (Haldol Decanoate) injections.
( X ) c.) Have the client's family begin commitment procedures so that her medication regimen can be supervised more closely.
( X ) d.) Refer the client to a partial hospitalization program so that she can participate regularly in group therapy sessions.
RATIONALE: For the client who is noncompliant with oral medication, depot medication is advantageous because the client will only need to keep one appointment every 2 to 4 weeks instead of taking medication daily. Education may or may not affect the client's compliance with medication. Long-term commitment is unnecessary at this time. Participation in a partial hospitalization program may be a desirable referral but would only indirectly affect the client's compliance with medication. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 639 _ about (MC)
QUESTION: "The client has been taking the monoamine oxidase inhibitor (MAOI) phenelzine (Nardil), 10 mg bid. The physician orders a selective serotonin reuptake inhibitor (SSRI), paroxetine (Paxil), 20 mg given every morning. The nurse:"
CHOICES
( X ) a.) Gives the medication as ordered.
( O ) b.) Questions the physician about the order.
( X ) c.) Questions the dosage ordered.
( X ) d.) Asks the physician to order benztropine (Cogentin) for the side effects.
RATIONALE: The nurse questions the physician about the order because the client who has been taking an MAOI such as phenelzine must wait 14 days after stopping the MAOI before starting an SSRI such as paroxetine. Serotonin syndrome, a potentially lethal consequence, can occur when combining an MAOI and an SSRI. Serotonin syndrome is characterized by hyperreflexia, hyperthermia, myoclonus, and other symptoms similar to neuroleptic malignant syndrome. Giving the medication as ordered can result in serious adverse consequences, as described above. The dosage is accurate. Benztropine is not given with an SSRI; it is an antiparkinsonian agent usually ordered for the side effects of antipsychotic medication. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 642 _ about (MC)
QUESTION: "A voluntary client has been taking haloperidol (Haldol) as prescribed. One morning, she refuses to take the Haldol. Which of the following actions should the nurse take?"
CHOICES
( X ) a.) Summon another nurse to help ensure that the client takes her medicine.
( X ) b.) Tell the client that she can take the medication either orally or by injection.
( O ) c.) Withhold the medication until it is determined why the client is refusing to take it.
( X ) d.) Tell the client that she needs to take her "vitamin" to stay healthy.
RATIONALE: The client has a legal right to refuse treatment. When a client refuses medication, the nurse must explore the reason for the refusal. The desire to avoid unwanted side effects is a common reason. Legally a client cannot be forcibly medicated unless she is a danger to herself or others or there is a court order to treat. Legally a client cannot be forcibly medicated unless she is a danger to herself or others or there is a court order to treat. Lying to a client about a medication is neither appropriate nor ethical. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 647 _ about (MC)
QUESTION: "The client is taking fluoxetine (Prozac) 20 mg at bedtime. He states that Prozac is not helping him to sleep. The nurse judges:"
CHOICES
( O ) a.) That the client should take Prozac in the morning.
( X ) b.) That dose is too high.
( X ) c.) That the client's symptoms of depression seem to be getting worse.
( X ) d.) That the client is on the wrong medication.
RATIONALE: Fluoxetine should be taken as early in the day as possible so as not to interfere with nighttime sleep; it may cause nervousness in some clients. The dose is therapeutic and not too high. There is no evidence in this situation to justify the conclusion that the client's depression is worsening. There is no evidence in this situation to justify the conclusion that the client is on the wrong medication. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 648 _ about (MC)
QUESTION: "A client with bipolar disorder, manic phase, has a nursing diagnosis of Imbalanced Nutrition: Less Than Body Requirements. To help the client meet recommended daily allowances of nutrients, which of the following nursing interventions would be best?"
CHOICES
( O ) a.) Give the client half of a meat and cheese sandwich between meals.
( X ) b.) Inform the client that snacks are available only if he eats properly at mealtime.
( X ) c.) Tell the client to sit alone at mealtime so that he won't be distracted by others.
( X ) d.) Teach the client about proper nutrition.
RATIONALE: The best nursing intervention is giving the client finger-foods high in protein and calories that he can eat while he paces or walks. Informing the client that snacks are available if he eats properly at mealtime is inappropriate because the client is too busy and distracted to sit and eat an entire meal. Telling the client to sit alone at mealtime to decrease distractions will not help him because the client is in a manic state, is easily distracted, and needs to move. Teaching the client about proper nutrition ignores his need for adequate intake. The client would be unable to focus on the nurse's teaching. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Basic care and comfort
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--> QUESTION NUMBER _ 653 _ about (MC)
QUESTION: "A client admits to using cocaine and says, "When I stop using, I feel bad." Which of the following effects is the client most likely to describe as occurring after he stops using cocaine?"
CHOICES
( O ) a.) Depression.
( X ) b.) Palpitations.
( X ) c.) Flashbacks.
( X ) d.) Double vision.
RATIONALE: Depression typically occurs after a person stops using cocaine. Some people experience formication and describe bugs crawling under the skin. Palpitations are not associated with cocaine withdrawal. Flashbacks are not associated with cocaine withdrawal. Double vision is not associated with cocaine withdrawal. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 656 _ about (MC)
QUESTION: "The nurse planning interventions for the victim of physical abuse would base the plan on knowledge that:"
CHOICES
( X ) a.) A woman in crisis is unlikely to be receptive to professional help.
( X ) b.) The client generally can control the batterer.
( O ) c.) Assessing the client's level of danger is a prerequisite to intervention.
( X ) d.) The victim will want to leave the abuser immediately.
RATIONALE: Assessing the client's level of danger is extremely important. The client and the children may be in serious danger if the perpetrator has threatened to kill them if they leave. Such an assessment is a prerequisite to intervention, which usually requires a multidisciplinary approach. A woman is more open to change and more receptive to professional intervention during a crisis. At other times, it is easier for her to deny the problems and maintain usual patterns of interaction. The client cannot control the batterer. She can only control her responses to the batterer and to the situation. The victim of abuse cannot be persuaded, rushed, or coerced into leaving the abuser before she is ready. This is often difficult for health care providers to understand. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 667 _ about (MC)
QUESTION: "Typically parents who abuse children:"
CHOICES
( X ) a.) Married at a very early age.
( X ) b.) Did not want any children.
( O ) c.) Were abused as children.
( X ) d.) Are disappointed in the sex of the child.
RATIONALE: Child abuse can be a vicious cycle because abused children often become abusive parents. Marrying at an early age is not necessarily associated with child abuse. Having unwanted children is not necessarily associated with child abuse. Being disappointed at the child's sex is not necessarily associated with child abuse. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 669 _ about (MC)
QUESTION: "Which of the following behaviors displayed by a 13-year-old boy dying of leukemia would most clearly indicate his need for emotional support?"
CHOICES
( O ) a.) Wanting to have someone with him at all times.
( X ) b.) Teasing his sister about her new boyfriend.
( X ) c.) Having the nurse wait with his bath while he makes a telephone call.
( X ) d.) Complaining about the limited number of choices on the dietary list.
RATIONALE: A client who wants to have someone with him at all times is asking for support because of his fear and anxiety. Teasing his sister is typical behavior and does not directly indicate a need for emotional support. Having the nurse wait while he uses the telephone does not directly indicate a need for emotional support. Complaining about his dietary choices does not directly indicate a need for emotional support. NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 670 _ about (MC)
QUESTION: "During hospitalization, a client with bulimia stops vomiting but becomes fearful that she will gain weight. She tells the nurse, "I can't gain weight. I'm fat enough as it is. I'll be really disgusting if I get fatter." When responding to this client, it would be most therapeutic for the nurse to:"
CHOICES
( X ) a.) Explain that the calories in her prescribed diet are not enough to cause weight gain.
( X ) b.) Encourage her to negotiate a calorie change with the nutritionist.
( X ) c.) Reassure her that the staff will take complete control of her eating and will prevent her from gaining weight in the hospital.
( O ) d.) Use nonjudgmental and realistic comments.
RATIONALE: Using nonjudgmental, realistic comments corrects the client's misperception without challenging or disagreeing with her verbalization of her thoughts and feelings. Reassurance about weight gain misses the point and probably will be rejected. Changing calories perpetuates the need to focus on eating and weight. Emphasizing the staff's control detracts from the client's sense of responsibility and capability to heal herself. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 672 _ about (MC)
QUESTION: "After talking with the nurse, a client admits to being physically abused by her husband. She says that she has never called the police because her husband has threatened to kill her if she does. She says, "I don't want to get him into trouble because he's the father of my children. I don't know what to do!" Which of the following nursing interventions would be most therapeutic at this time?"
CHOICES
( X ) a.) Help the client identify the behaviors that provoke the abuse.
( X ) b.) Teach the client ways to reduce stress within her family.
( O ) c.) Express concern for the client's safety.
( X ) d.) Tell the client that she should leave her husband.
RATIONALE: The nurse's expression of concern for the client's safety may help the client validate her fears and choose to take action. Talking to the client about changing her behavior is a form of victim blaming. They reinforce the message that the client is responsible for the abuse. She is likely getting the same message from the abuser and others. Talking to the client about reducing family stress is also a form of victim blaming. Telling her to leave her husband is inappropriate advice. The idea of leaving the marriage may be so overwhelming that it may push the client away from the nurse as a support person. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 676 _ about (MC)
QUESTION: "A client with an obsessive-compulsive disorder washes his feet frequently. Which of the following nursing diagnoses is specifically related to this behavior?"
CHOICES
( X ) a.) Self-Care Deficit.
( X ) b.) Ineffective Coping.
( O ) c.) Risk for Impaired Skin Integrity.
( X ) d.) Anxiety.
RATIONALE: The nursing diagnosis Risk for Impaired Skin Integrity related to frequent foot washing is indicated. The skin of the feet can become red and raw, providing an entry for infection. Self-Care Deficit refers to an impaired ability to care for basic physical needs. This client can provide self-care. Ineffective Coping refers to an inability to problem-solve and adaptively cope with life's demands and roles. This diagnosis might apply to the client with obsessive compulsive behaviors, but it does not directly address the problems associated with this client's foot washing behavior. The ritualistic behavior provides relief for the client's anxiety and keeps it in check, but this diagnosis does not directly address the problems associated with this client's foot washing behavior. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 677 _ about (MC)
QUESTION: "The client states he washes his feet endlessly because they "are so dirty that I can't put on my socks and shoes." The nurse recognizes the client is using ritualistic behavior primarily to relieve discomfort associated with feelings of:"
CHOICES
( O ) a.) Intolerable anxiety.
( X ) b.) Depression.
( X ) c.) Ambivalence.
( X ) d.) Irrational fear.
RATIONALE: The client with an obsessive-compulsive disorder has an uncontrollable and persistent need to perform behavior that helps relieve intolerable anxiety. In depression, the client feels extreme sadness. Depression is not alleviated by performing obsessive-compulsive actions. Ambivalence refers to two simultaneous opposing feelings. An irrational fear is called a phobia. Phobic behavior is associated with extreme avoidance behavior when confronted with the feared object, not with ritualistic behaviors. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 682 _ about (MC)
QUESTION: "Which of the following nursing actions would be least helpful for a battered client?"
CHOICES
( X ) a.) Giving her information about a safe home and a crisis help line telephone number.
( O ) b.) Helping the client displace her feelings
( X ) c.) Teaching the client about the cycle of violence.
( X ) d.) Discussing the client's legal and personal rights.
RATIONALE: When working with a battered woman, the nurse should help her share and discuss her anger, frustration, guilt, shame, and other feelings. Displacing, ie, placing feelings onto another person or object, is not helpful to the client and is not a healthy way for her to handle her feelings. Informing the client of safe homes and crisis lines is one of the issues the nurse should address with the battered client. Teaching her about the cycle of violence is one of the issues the nurse should address with the battered client. Informing the client about legal and personal rights is one of the issues the nurse should address with the battered client. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 683 _ about (MC)
QUESTION: "The client with a cognitive disorder tells the nurse, "Everyone is after me. They want to kill me." The nurse's best response is:"
CHOICES
( O ) a.) "You're frightened. This is a hospital and these people are staff members. You're safe here."
( X ) b.) "Why do you think someone wants to kill you?"
( X ) c.) "No one wants to kill you. We like you."
( X ) d.) "Don't worry, we'll protect you. No one can come here to harm you."
RATIONALE: The nurse does not argue with the client having delusions. The nurse addresses the client's underlying feeling and presents reality to promote the client's trust, comfort, and sense of reality. This statement challenges the client and further distances the client from reality. This statement defends the staff and does not address the client's feeling. This statement validates the client's delusion, does not address the client's feeling, and may further confuse the client. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 689 _ about (MC)
QUESTION: "At an emergency shelter, an earthquake victim tells the nurse that he is going to spend the night in his own bed at home. Which defense mechanism is the client exhibiting?"
CHOICES
( X ) a.) Intellectualization.
( O ) b.) Denial.
( X ) c.) Rationalization.
( X ) d.) Undoing.
RATIONALE: Denial is an unconscious refusal to admit an unacceptable idea or behavior. It protects the client in this crisis situation by blocking out the earthquake from conscious awareness. Intellectualization is the use of logical explanations without feelings. Rationalization is the attempt to prove that one's feelings are justifiable. Undoing is doing something to make up for a wrongdoing. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 703 _ about (MC)
QUESTION: "A client describes anxiety attacks that usually occur shortly after work when he is preparing his evening meal. Which of the following questions would be most appropriate for the nurse to ask the client first in an effort to learn how he can be helped?"
CHOICES
( X ) a.) "Have you tried walking to ease your anxiety?"
( O ) b.) "What are you thinking about before you start to prepare supper?"
( X ) c.) "Do you think taking several slow, deep breaths would help?"
( X ) d.) "What do you do when you're anxious to help yourself feel better?"
RATIONALE: The nurse initially helps the client to identify a cause or event that precedes the symptoms of anxiety. Nursing care of an anxious client, however, must ultimately take into account all aspects of the client's anxiety including what leads to attacks and what happens during an attack. Only then can the nurse help the client understand his anxiety, what personal needs may be unmet, and how to cope with his problem with more satisfactory behavior than having an anxiety attack. The nurse must first assess the possibility of a trigger for the client's anxiety before progressing to assessing the client's coping strategies or educating him regarding adaptive coping. The nurse must first asses the possibility of a trigger for the client's anxiety before progressing to assessing the client's coping strategies or educating him regarding adaptive coping. The nurse must first asses the possibility of a trigger for the client's anxiety before progressing to assessing the client's coping strategies or educating him regarding adaptive coping. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 705 _ about (MC)
QUESTION: "A client's nursing diagnosis is Chronic Low Self-Esteem related to self-doubt as evidenced by self-deprecatory statements. Which of the following expected outcomes specifically relates to this diagnosis? The client will:"
CHOICES
( O ) a.) Identify positive aspects of self.
( X ) b.) Demonstrate reality-based thinking.
( X ) c.) Use relaxation exercises.
( X ) d.) Set attainable goals.
RATIONALE: The expected outcome that the client identify positive aspects of self specifically relates to the nursing diagnosis of Chronic Low Self-esteem related to self-doubt as evidenced by self-deprecatory comments. An expression of positive self comments indicates a realistic view of the client's self-concept. Demonstrating reality-based thinking relates to altered thought processes. Using relaxation exercises relates more to decreasing anxiety. Setting attainable goals relates to hopelessness. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 712 _ about (MC)
QUESTION: "The nurse attempts to interact with a client who barely responds with yes or no. The client states, "Don't bother me. I want to die." The nurse's best action is to:"
CHOICES
( X ) a.) Leave the client alone.
( X ) b.) Send another staff member to interact with the client.
( O ) c.) Sit with the client for 10 minutes.
( X ) d.) Turn on the television for the client.
RATIONALE: The nurse sits in silence with the client who is severely depressed. The nurse's presence conveys concern for and acceptance of the client, provides security, increases self-worth, and gives some structure to the client's day. Leaving the client alone ignores the client's needs and does nothing to foster trust in the nurse. Sending another staff member to interact with the client does not help the client gain trust and may be interpreted as the nurse not wanting to be "bothered." Turning on the television for the client completely blocks communication and diverts attention away from the client's needs. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 715 _ about (MC)
QUESTION: "The client is taking risperidone (Risperdal) to treat the positive and negative symptoms of schizophrenia. Which of the following symptoms is negative?"
CHOICES
( X ) a.) Abnormal thought form.
( X ) b.) Hallucinations and delusions.
( X ) c.) Bizarre behavior.
( O ) d.) Asocial behavior and anergia.
RATIONALE: Asocial behavior, anergia, alogia, and affective flattening are some of the negative symptoms of schizophrenia that may improve with risperidone therapy. Abnormal thought form is a positive symptom of schizophrenia. Hallucinations and delusions are positive symptoms of schizophrenia. Bizarre behavior is a positive symptom of schizophrenia. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 719 _ about (MC)
QUESTION: "The client with an Axis I diagnosis of Schizophrenia: disorganized type walks into group naked. The nurse's best action is to:"
CHOICES
( X ) a.) Instruct the client to go to his room and to put on some clothes.
( X ) b.) Wrap a blanket around him and tell him to be seated for the remainder of group.
( X ) c.) Ask a male client to take off his sweater and wrap it around the client's waist.
( O ) d.) Lead the client to his room and help him dress if he needs assistance.
RATIONALE: The best nursing action is to lead the client to his room and assist him with putting on his clothes. The client with disorganized behavior needs the nurse's assistance to protect his self-esteem and dignity and to avoid embarrassment. Instructing the client to go to his room to put on his clothes may not be effective because the client may be too disorganized to follow directions. Wrapping a blanket around the client is helpful. Instructing him to be seated for the remainder of group is inappropriate and demeaning. Asking another client to remove his sweater and wrap it around the other client's waist is inappropriate. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 730 _ about (MC)
QUESTION: "Two days after a client's wife and child were found dead in a flood, the client returns to the crisis center and says he thinks it would be better to "end it all right now and join my wife and kid, wherever they are." The nurse has already determined that the client has no history of psychiatric problems. In terms of the seriousness of the client's suicide threat, his risk should be considered as:"
CHOICES
( O ) a.) High; the client's suicide threat can be considered a call for help and should be taken seriously.
( X ) b.) Very low; as long as the client speaks of suicide, he is unlikely to carry out the act.
( X ) c.) Low; a person who has not had psychiatric problems in the past rarely carries out a first suicide threat.
( X ) d.) Moderate; the client appears to be making an effort to gain attention and extra support.
RATIONALE: The client who threatens suicide should be considered at high risk. His threat should be taken seriously, as a call for help. It is untrue that people who talk about suicide will not do it. It is untrue that a person without a history of psychiatric problems will be unlikely to carry out a first threat. It is a common misconception that a suicide threat is only a bid for attention. All comments about suicide should be taken seriously. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 737 _ about (MC)
QUESTION: "A client is admitted to the inpatient psychiatric unit. He is unshaven, has body odor, and has spots on his shirt and pants. He moves slowly, gazes at the floor, and has a flat affect. The nurse's highest priority in assessing the client on admission would be to ask him:"
CHOICES
( X ) a.) How he sleeps at night.
( O ) b.) If he is thinking about hurting himself.
( X ) c.) About recent stresses.
( X ) d.) How he feels about himself.
RATIONALE: The nurse's highest priority is to ask the client if he is thinking about hurting himself or to assess for suicide. Questioning the client about his sleep pattern is an important area of assessment for the depressed client but not as immediate a priority as assessing the Risk for Suicide. Questioning the client about recent stresses is an important area of assessment for the depressed client but not as immediate a priority as assessing the Risk for Suicide. Questioning the client his feelings about himself is an important area of assessment for the depressed client but not as immediate a priority as assessing the Risk for Suicide. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 739 _ about (MC)
QUESTION: "The nurse judges a client to no longer need constant one-to-one observation for self-directed violence when the client:"
CHOICES
( X ) a.) Begins to interact with the nurse.
( O ) b.) Stops putting his head in the toilet to drown himself.
( X ) c.) Displays a sudden elevation in mood.
( X ) d.) Eats his meals in the dining room.
RATIONALE: The nurse judges the client to no longer require constant one-to-one observation when the client stops putting his head in the toilet to drown. Interacting with the nurse does not indicate anything about the client's potential for self-directed violence. A sudden elevation in mood may indicate relief about ambivalent feelings and thoughts about killing himself and may be a signal that a suicide attempt is imminent. Eating meals in the dining room does not indicate anything about the client's potential for self-directed violence. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 741 _ about (MC)
QUESTION: "The nurse is conducting a mental status examination on a client with a cognitive disorder. Which of the following statements does the nurse judge to be an impairment in abstract thinking? The client's:"
CHOICES
( X ) a.) Ability to remember her wedding day.
( O ) b.) Inability to find a similarity between a bird and a butterfly.
( X ) c.) Memories regarding her vacation 5 years ago.
( X ) d.) Inability to state her home address.
RATIONALE: Impairment in abstract thinking is demonstrated by the client's inability to find a similarity between a bird and a butterfly. The client's ability to remember her wedding day demonstrates intact long-term memory. The client's ability to remember her vacation 5 years ago demonstrates intact long-term memory. The client's inability to state her home address demonstrates impairment in short-term memory. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 742 _ about (MC)
QUESTION: "A client is admitted to the emergency department with a cut finger that is bleeding profusely. She displays signs of alcohol intoxication, and a blood test confirms this. After the client's wound is sutured but before she leaves the emergency department, it would be best for the nurse to ensure that the client:"
CHOICES
( O ) a.) Takes a nap.
( X ) b.) Does some exercising.
( X ) c.) Restricts fluid intake.
( X ) d.) Drinks generous amounts of black coffee.
RATIONALE: It is best to overcome the effects of excessive alcohol intake by sleeping. Alcohol is not used directly by muscle cells; therefore, physical activity does not affect the rate at which alcohol is removed from the bloodstream. Restricting fluids does not hasten removal of alcohol from the body. Drinking black coffee does not hasten removal of alcohol from the body. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 745 _ about (MC)
QUESTION: "Which of the following statements that the nurse makes to a client suspected of being abused would most likely encourage her to admit and describe her abuse?"
CHOICES
( O ) a.) "Who is doing this to you?"
( X ) b.) "How did you hurt yourself?"
( X ) c.) "When were you in an accident?"
( X ) d.) "How long have you had these bruises?"
RATIONALE: A direct, open-ended question from the nurse helps the client describe her problem and achieve relevance and depth. Statements that help the client avoid the issue are least helpful. Statements that help the client avoid the issue are least helpful. This statement entirely avoids the issue of how the client became injured. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 827 _ about (MC)
QUESTION: "The client who has had hepatitis A should be instructed never to:"
CHOICES
( X ) a.) Drink alcohol.
( O ) b.) Donate blood.
( X ) c.) Smoke.
( X ) d.) Eat fatty foods.
RATIONALE: These clients should never donate blood. Moderation in alcohol consumption is recommended. Smoking, although unhealthful, is not contraindicated for clients who have hepatitis. Uncomplicated hepatitis A does not require modification of fat intake. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Safe, effective care environment CLIENT NEEDS SUBCATEGORY: Safety and infection control
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--> QUESTION NUMBER _ 1077 _ about (MC)
QUESTION: "A client has been treated for major depression and is taking antidepressants. He asks the nurse, "How long do I have to take these pills?" Which is the
CHOICES
( X ) a.) "Once you are feeling better the medication can be discontinued."
( X ) b.) "You will need to take the medication for at least 3 months."
( O ) c.) "Antidepressants are prescribed for 6 to 12 months before considering discontinuation."
( X ) d.) "The medication can be discontinued when you do not have suicidal thoughts."
RATIONALE: With major depression, antidepressants are prescribed for 6 to 12 months before the client is evaluated for discontinuation. An adequate duration for maintenance treatment is a minimum of 6 months; it is often longer depending on the stage of the illness and the specific client's characteristics. This regime must be explained to clients as they often want to stop the medication when they feel better. An adequate duration for maintenance treatment is a minimum of 4 to 5 months; it is often longer depending on the stage of the illness and the specific client's characteristics. Discontinuation of the medication prematurely may cause a relapse. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1078 _ about (CM)
QUESTION: "A client is prescribed escitalopram (Lexapro) 10 mg qd. The nurse would be alert for the development of which of the following as possible adverse effects? Select all that apply."
CHOICES
( X ) a.) Postural hypotension
( O ) b.) Nausea
( O ) c.) Sexual dysfunction
( X ) d.) Sedation
( O ) number="5">Insomnia
RATIONALE: Escitalopram (Lexapro) is a selective serotonin reuptake inhibitor (SSRI). Common adverse effects include nausea or GI disturbances, insomnia, diaphoresis, fatigue, somnolence, and sexual dysfunction such as delayed ejaculation and anorgasmia. Postural hypotension and sedation are associated with the use of tricyclic antidepressants.
NURSING PROCESS STEP: Assessment CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1079 _ about (CM)
QUESTION: "A 76-year-old client has been taking amitriptyline (Elavil) 75 mg in divided doses daily. The nurse would be most concerned if the client developed which of the following? Select all that apply."
CHOICES
( O ) a.) Postural hypotension
( O ) b.) Sedation
( X ) c.) Insomnia
( O ) d.) Tachycardia
( X ) number="5">Dry mouth
RATIONALE: Amitriptyline (Elavil) is not a first-choice agent for older adults due to its adverse effect profile. It is highly anticholinergic, sedating, and cardiotoxic. It also causes postural hypotension. Insomnia is not an adverse effect associated with tricyclic antidepressants. Even though dry mouth is possible, the nurse would be most concerned with the presence of postural hypotension, tachycardia, and sedation due to the risk for injury and possible physiological compromise. NURSING PROCESS STEP: Analysis CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1080 _ about (CM)
QUESTION: "A client is hospitalized in a medical unit for stabilization of his hypertension, dementia, and diabetes after it was confirmed that he suffered a third mini-stroke within 5 months. The hospital chaplain saw the client and family and then says to the nurse, "The family is so ambivalent about arranging for a nursing home now, even though they know it is inevitable." Which of the following responses to the chaplain would be most appropriate? Select all that apply."
CHOICES
( X ) a.) "The social worker has many names of reputable nursing homes."
( X ) b.) "We can help the family with that decision; we do it all the time."
( O ) c.) "It is premature to recommend a nursing home at this time."
( O ) d.) "Stabilizing his hypertension and diabetes could reduce the risk of strokes."
( O ) number="5">"It's possible that medication could reduce the risk of more blood clots."
RATIONALE: Uncontrolled hypertension, diabetes, and blood clots can increase the progression of vascular dementia. Treating the underlying causes may prevent or slow the progress of this form of dementia. It is premature to recommend long-term care before stabilization of the medical conditions occurs. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 1081 _ about (CM)
QUESTION: "The nurse is preparing a short presentation at a National Alliance for the Mentally Ill meeting with clients and families. The topic is on early signs of relapse in clients with chronic mental illnesses. Which of the following signs would be the most important to include? Select all that apply."
CHOICES
( O ) a.) Decrease in sleep and self-care.
( O ) b.) Increase in social isolation and withdrawal.
( X ) c.) Obvious delusions and hallucinations.
( O ) d.) More fears and suspiciousness.
( X ) number="5">Suicidal or homicidal threats.
RATIONALE: Early signs of relapse most frequently include a decrease in sleep and self-care, increased withdrawal or social isolation, and increased fears or suspiciousness. Obvious delusions, hallucinations, and suicidal or homicidal threats are much later indicators of relapse. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Health promotion and maintenance CLIENT NEEDS SUBCATEGORY: None
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--> QUESTION NUMBER _ 1082 _ about (CM)
QUESTION: "After teaching a client about lorazepam (Ativan), which of the following client statements indicates the need for further teaching? Select all that apply."
CHOICES
( X ) a.) "I can chew sugarless gum if my mouth feels dry."
( O ) b.) "I can adjust the dose when I feel more anxious."
( X ) c.) "I should not drink alcohol."
( X ) d.) "I can take Ativan with food if I get nauseous."
( O ) number="5">"I can stop taking Ativan immediately if I need to."
RATIONALE: Lorazepam (Ativan), a benzodiazepine, is used as an anti-anxiety agent and depresses the central nervous system. Benzodiazepines cause physical dependence and tolerance and should never be stopped abruptly because withdrawal symptoms can occur. Slow tapering is required to minimize withdrawal symptoms. The client should not adjust the dose when feeling anxious because of tolerance and the possibility of overdose. Common central nervous system (CNS) adverse effects are drowsiness, fatigue, and incoordination. Other side effects, such as dry mouth, can be helped by rinsing the mouth and using sugarless gum and candy. The drug can be taken with food if the client experiences nausea. The use of alcohol and other CNS depressants can further CNS depression. NURSING PROCESS STEP: Evaluation CLIENT NEEDS CATEGORY: Physiological integrity CLIENT NEEDS SUBCATEGORY: Pharmacological and parenteral therapies
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--> QUESTION NUMBER _ 1083 _ about (CM)
QUESTION: "In a children's unit team meeting, staff is working on protocols for dealing with clients with autistic disorder (autism). Which of the following categories of protocols would be most important? Select all that apply."
CHOICES
( O ) a.) Protections for harm to self and others.
( O ) b.) Preparation for any changes in unit routines.
( X ) c.) Limitations on toys allowed.
( X ) d.) Types of verbalizations expected.
( O ) number="5">Reinforcements for appropriate interactions with peers and staff.
RATIONALE: Children with autism may have behaviors such as head banging or pinching that harm themselves or others. They have a strong need for sameness and need to be prepared for changes. Any client efforts to interact appropriately needs to be reinforced, because social behaviors are typically limited. What toys these clients have is not as important as what they do with them, such as throwing them at others. Depending on the severity of the autism, their verbalizations vary significantly, so a protocol for this is not possible. NURSING PROCESS STEP: Planning CLIENT NEEDS CATEGORY: Safe effective care environment CLIENT NEEDS SUBCATEGORY: Management of care
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--> QUESTION NUMBER _ 1084 _ about (CM)
QUESTION: "Which of the following approaches would be most therapeutic for clients with borderline personality disorders? Select all that apply."
CHOICES
( X ) a.) Offering solutions for problems.
( X ) b.) Interacting on a superficial level.
( O ) c.) Assisting with management of emotions.
( O ) d.) Using supportive confrontation when needed.
( X ) number="5">Minimizing fears regarding responsibility for self.
RATIONALE: When intervening with clients with borderline personality disorder, the nurse assists with management of emotions related to mood shifts, especially anger and rage, to decrease acting-out behaviors, self-mutilation, and suicidal behaviors. The use of supportive confrontation, limit-setting, and consistency are necessary interventions that provide clients with clear expectations regarding their behaviors. Offering solutions for problems and interacting on a superficial level may be easier for the nurse but not helpful for clients who must learn to make their own decisions and be responsible for self. The nurse may feel frustrated and ineffective as a caregiver because of the clients' behaviors and defenses but must understand the dynamics of the disorder to offer proper therapy. NURSING PROCESS STEP: Implementation CLIENT NEEDS CATEGORY: Psychosocial integrity CLIENT NEEDS SUBCATEGORY: None
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