Nokea
A 22 year-old patient in a mental health lock-down unit under suicide watch appears happy about being discharged. Which of the following is probably happening?
- A. The patient is excited about being around family again.
- B. The patient's suicide plan has probably progressed.
- C. The patient's plans for the future have been clarified.
- D. The patient's mood is improving.
Correct Answer: B
Rationale: The suicide plan may have been decided.
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Several days after a client had a myocardial infarction, the physician placed him on a 2-gm sodium diet.
Which of the following selections would indicate to the nurse an understanding of the diet?
- A. Scrambled egg, orange slices, and milk.
- B. Instant oatmeal, toast, and orange juice.
- C. Poached egg, bacon, and milk.
- D. Biscuit, fruit cup, and sausage.
Correct Answer: A
Rationale: Strategy: Determine the foods that are allowed on a 2-gm sodium diet. (1) correct-all items are low in sodium; milk is allowed on a salt-restricted diet (2) instant oatmeal has sodium added (3) bacon is high in sodium (4) all baked breads are high in sodium, as is sausage
A victim of domestic violence states to the nurse, 'If only I could change and be how my companion wants me to be, I know things would be different.' Which would be the best response by the nurse?
- A. The violence is temporarily caused by unusual circumstances, don't stop hoping for a change.
- B. Perhaps, if you understood the need to abuse, you could stop the violence.
- C. No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?
- D. Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do.
Correct Answer: D
Rationale: Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do. This clarifies that the abuser is responsible for the violence.
A child at summer camp comes to see the camp nurse 10 minutes after being stung by a bee. The child complains of tingling around her mouth and tightness in her chest. The nurse's first action is summon help and to:
- A. Administer $\mathrm{O}_2$ at $4 \mathrm{~L} / \mathrm{min}$ by nasal cannula.
- B. Apply a tourniquet proximal to the bee sting and give epinephrine subcutaneously.
- C. Administer $\mathrm{O}_2$ at $6 \mathrm{~L} / \mathrm{min}$ and give Benadryl (Diphenhydramine) $25 \mathrm{mg}$ PO.
- D. Reassure the child that she is only excited due to the sting.
Correct Answer: B
Rationale: Tingling and chest tightness suggest anaphylaxis; epinephrine is the first-line treatment, and a tourniquet may slow venom spread.
A client is admitted to the emergency room in severe emotional distress. The client's respirations are 42/min, and the blood gases reveal a pH of 7.5 and a PaCO2 of 34.
Initially the nurse should
- A. instruct the client to breathe into a paper bag.
- B. start an IV of D5W.
- C. administer O2.
- D. have the client place his head between his knees.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-because of hyperventilation, client is in alkalosis; having him rebreathe his own carbon dioxide will reverse his blood gas imbalance (2) does not address the problem (3) is not hypoxic (4) is done when a client feels faint
The nurse is caring for a client with a history of systemic lupus erythematosus.
- A. Which symptom is expected in a client with systemic lupus erythematosus?
- B. Chest pain and shortness of breath.
- C. Fever and joint pain.
- D. Weight gain and edema.
- E. Persistent headaches.
Correct Answer: B
Rationale: Fever and joint pain are common in systemic lupus erythematosus due to autoimmune inflammation. Chest pain may occur with pericarditis, but weight gain and headaches are less specific.