Nokea
A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of:
- A. Depression
- B. Agitation
- C. Psychotic ideation
- D. Anhedonia
Correct Answer: B
Rationale: Signs of depression would include withdrawal, sadness, morbid thoughts, insomnia, early awakening, etc. These clinical features are classic signs of agitation. Psychotic ideation includes delusional thoughts, bizarre behavior, disorganized thinking, etc. Anhedonia is the inability to experience pleasure.
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The mother of a client is apprehensive about taking home her 2 year old who was diagnosed with asthma after being admitted to the emergency room with difficulty breathing and cyanosis. She asks the nurse what symptoms she should look for so that this problem will not happen again. The nurse instructs her to watch for the following early symptoms:
- A. Fever, runny nose, and hyperactivity
- B. Changes in breathing pattern, moodiness, fatigue, and edema of eyes
- C. Fatigue, dark circles under the eyes, changes in breathing pattern, glassy eyes, and moodiness
- D. Fever, cough, paleness, and wheezing
Correct Answer: C
Rationale: The child with asthma may not have fever unless there is an underlying infection. Edema of the eyes will not be present because the child with asthma is more likely to have dehydration related to excessive water loss during the work of breathing. All of these symptoms indicate decreased oxygenation and are early symptoms of asthma. Coughing and wheezing are not early signs of difficulty.
A client with a right lobectomy is being transported from the intensive care unit to a medical unit. The nurse understands that the client's chest drainage system:
- A. Can be disconnected from suction if the chest tube is clamped
- B. Can be disconnected from suction, but the chest tube should remain unclamped
- C. Must remain connected by means of a portable suction
- D. Must be kept even with the client's shoulders during the transport
Correct Answer: B
Rationale: The chest drainage system can be disconnected from suction during transport, but the tube must remain unclamped to allow air or fluid to escape, preventing pneumothorax. Portable suction is not always needed.
A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the client's self-esteem by:
- A. Adhering to a strict schedule of diet, exercise, and wound care
- B. Allowing him to go to physical therapy for whirlpool treatment when other clients were not in physical therapy
- C. Following a standardized plan of care for burn clients formulated by a world-renowned burn center
- D. Allowing him to plan, assist in, and perform his own care whenever possible
Correct Answer: D
Rationale: A regimented schedule, allowing no flexibility, will not foster the client's self-esteem. Isolating the client may only enhance his feelings of social isolation due to his disfigurement. Standardized care plans must be personalized and adapted to each client's situation. Allowing the client control over his care will foster his self-esteem and prepare him for life outside of the hospital.
The nurse is caring for a client with a history of a colostomy who is experiencing leakage around the stoma. The nurse should:
- A. Apply a larger appliance
- B. Clean the stoma with alcohol
- C. Check the skin barrier fit
- D. Irrigate the colostomy
Correct Answer: C
Rationale: Leakage around a colostomy stoma often indicates a poor skin barrier fit, requiring adjustment or resizing. Larger appliances, alcohol, and irrigation do not address the issue.
A client with rheumatoid arthritis is beginning to develop flexion contractures of the knees. The nurse should tell the client to:
- A. Lie prone and let her feet hang over the mattress edge
- B. Lie supine, with her feet rotated inward
- C. Lie on her right side and point her toes downward
- D. Lie on her left side and allow her feet to remain in a neutral position
Correct Answer: A
Rationale: Lying prone with feet hanging over the mattress edge helps stretch the knee joints and prevent flexion contractures in rheumatoid arthritis. The other positions do not address knee extension.