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18. Melatonin’s use is based on scientific evidence. The patient with which problem would benefit from melatonin?
- A. Sleep problems
- B. Mild depression
- C. High cholesterol
- D. Benign prostatic hyperplasia
Correct Answer: A
Rationale: Melatonin is scientifically supported for addressing sleep problems (option A), such as insomnia or jet lag.
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The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that:
- A. The client should remain on bed rest in a semi-Fowler's position.
- B. The client should alternate ambulation with bed rest with legs elevated.
- C. The client may ambulate and sit in chair as tolerated.
- D. The client may ambulate as tolerated and remain in semi-Fowlers positioning bed.
Correct Answer: D
Rationale: Semi-Fowler's position aids in breathing and reduces pressure on the abdomen.
A client is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?
- A. Continue to monitor the client as this is an expected finding.
- B. Add more water to the suction control chamber of the drainage system.
- C. Verify that the suction regulator is on and check the tubing for leaks.
- D. Milk the chest tube and dislodge any clots in the tubing that are occluding it.
Correct Answer: C
Rationale: The correct answer is C: Verify that the suction regulator is on and check the tubing for leaks.
Rationale:
1. Lack of bubbling in the suction control chamber indicates suction may not be working.
2. Checking the suction regulator ensures it is on and at the correct level for proper drainage.
3. Checking tubing for leaks ensures the system is intact and functioning properly.
4. This intervention addresses the potential issue of inadequate suction, which can affect the client's postoperative recovery.
Summary:
- Option A: Continuing to monitor is not appropriate as lack of bubbling suggests an issue with suction.
- Option B: Adding more water to the suction control chamber is unnecessary and does not address the root cause.
- Option D: Milking the chest tube is not recommended as it can cause trauma and dislodging clots may lead to complications.
Stephen Douglas has been in an automobile accident. The most effective IV solution for a patient having hypovolemic shock would be:
- A. hypertonic.
- B. isotonic.
- C. hypotonic.
- D. colloids.
Correct Answer: B
Rationale: Hypertonic IV fluids would be used to draw fluid off tissue in edematous situations such as third spacing. Isotonic solutions are used to increase intravascular volume, to increase perfusion of vital organs. Hypotonic fluids are used to rehydrate tissue in those with severe, or prolonged fluid deprivation. Colloids increase tonicity of intravascular fluids, pulling water into the vascular system from tissue.
The main goal of treatment for acute glomerulonephritis is to
- A. encourage activity.
- B. encourage high protein intake.
- C. maintain fluid balance.
- D. teach intermittent urinary catheterization.
Correct Answer: C
Rationale: Maintaining fluid balance is critical in managing acute glomerulonephritis due to potential fluid overload.
A nursing department in an acute care setting decides to redesign its nursing practice based on a theoretical framework. The feedback from patients, families, and staff reflects that caring is a key element. Which theorist best supports this concept?
- A. Erikson.
- B. Maslow.
- C. Rogers.
- D. Watson.
Correct Answer: D
Rationale: Jean Watson's theory emphasizes the importance of caring in nursing.