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A 22-year-old single woman was admitted to the psychiatric hospital by her mother, who reported bizarre behavior. Except for going to work, she spends all her time in her room and expresses concern over neighbors spying on her. She has fears of the telephone being 'bugged.' Her diagnosis is schizophrenia. One nurse per shift is assigned to work with the client. The primary reason for this plan would be to:
- A. Protect her from suicide
- B. Enable her to develop trust
- C. Supervise her medication regimen
- D. Involve her in groups for social interaction
Correct Answer: B
Rationale: The client is suspicious and needs help to develop trust, which is basic to her improvement. Consistent nursing assignment fosters a therapeutic relationship.
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A 45-year-old male client experiences a sense of depression because he has not yet achieved his life's goals. His career has not been satisfying. He is still looking for the right job. His wife spends too much money, and his children seem to ignore him while being very selfish. He is tired of all of their attitudes and is considering buying a red Corvette convertible. While obtaining these data concerning the client's feelings about his life, the nurse is able to determine he is experiencing what psychological crisis according to Erikson's stages?
- A. Identity versus role confusion
- B. Integrity versus despair
- C. Intimacy versus isolation
- D. Generativity versus self-absorption
Correct Answer: D
Rationale: Identity versus role confusion is experienced by adolescents making the transition from childhood to adulthood as they attempt to develop a sense of identity. Integrity versus despair is experienced by the elderly as they reflect on their life in an attempt to find meaning. Intimacy versus isolation is experienced by young adults as they establish intimate bonds of love and friendship. Generativity versus self-absorption is experienced by middle-aged adults as they fulfill life goals that involve family, career, and society. The client is experiencing this crisis.
A client with a history of trigeminal neuralgia is admitted with complaints of facial pain. The nurse should give priority to:
- A. Administering analgesics
- B. Monitoring blood pressure
- C. Providing a quiet environment
- D. Administering oxygen
Correct Answer: A
Rationale: Trigeminal neuralgia causes severe facial pain, so administering analgesics is the priority to relieve discomfort.
The nurse is caring for a client with a history of a pulmonary embolism who is receiving Warfarin (Coumadin). The nurse should monitor the client for:
- A. Bleeding
- B. Hypertension
- C. Tachypnea
- D. Fever
Correct Answer: A
Rationale: Warfarin, an anticoagulant, increases bleeding risk, requiring monitoring for signs like epistaxis or hematuria. Hypertension, tachypnea, and fever are not primary concerns.
The physician has ordered intubation and mechanical ventilation for a client with periods of apnea following a closed head injury. Arterial blood gases reveal a pH of 7.47, PCO2 of 28, and HCO3 of 23. These findings indicate that the client has:
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: B
Rationale: A pH of 7.47 (alkaline) with low PCO2 (28) indicates respiratory alkalosis, likely from hyperventilation due to brain injury. Normal HCO3 rules out metabolic causes.
A 74-year-old female client is 3 days postoperative. She has an indwelling catheter and has been progressing well. While the nurse is in the room, the client states, 'Oh dear, I feel like I have to urinate again!' Which of the following is the most appropriate initial nursing response?
- A. Assure her that this is most likely the result of bladder spasms.
- B. Check the collection bag and tubing to verify that the catheter is draining properly.
- C. Instruct her to do Kegel exercises to diminish the urge to void.
- D. Ask her if she has felt this way before.
Correct Answer: B
Rationale: The most frequent reason for an urge to void with an indwelling catheter is blocked tubing, so checking the catheter's patency is the best initial response.