Nokea
A cardinal symptom of the schizophrenic client is hallucinations. A nurse identifies this as a problem in the category of:
- A. Impaired communication
- B. Sensory-perceptual alterations
- C. Altered thought processes
- D. Impaired social interaction
Correct Answer: B
Rationale: Impaired communication refers to decreased ability or inability to use or understand language in an interaction. In sensory-perceptual alterations an individual has distorted, impaired, or exaggerated responses to incoming stimuli (i.e., a hallucination, which is a false sensory perception that is not associated with real external stimuli). An altered thought processes problem statement is used when an individual experiences a disruption in cognitive operations and activities (i.e., delusions, loose associations, ideas of reference). In impaired social interaction, the individual participates too little or too much in social interactions.
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A client with vaginal cancer is being treated with a radioactive vaginal implant. The client's husband asks the nurse if he can spend the night with his wife. The nurse should explain that:
- A. Overnight stays by family members is against hospital policy.
- B. There is no need for him to stay because staffing is adequate.
- C. His wife will rest much better knowing that he is at home.
- D. Visitation is limited to 30 minutes when the implant is in place.
Correct Answer: D
Rationale: Radioactive implants emit radiation posing a risk to others. Visitation is limited to short periods (e.g. 30 minutes) to minimize radiation exposure. The other options do not address the safety concern related to radiation.
A client with a history of epilepsy is admitted with status epilepticus. The nurse should give priority to:
- A. Administering oxygen
- B. Protecting the airway
- C. Administering anticonvulsants
- D. Monitoring blood pressure
Correct Answer: B
Rationale: In status epilepticus, prolonged seizures can obstruct the airway, so protecting the airway is the priority to ensure oxygenation and prevent asphyxia.
The client is admitted with a diagnosis of abruptio placenta. Which complication is most likely to occur?
- A. Fetal distress
- B. Maternal hemorrhage
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Abruptio placenta causes placental separation leading to fetal distress (from hypoxia) and maternal hemorrhage (from bleeding). Both are common and serious complications.
The nurse is caring for a client with a history of a stroke who has expressive aphasia. The nurse should:
- A. Speak loudly to the client
- B. Use simple, short sentences
- C. Provide a whiteboard for communication
- D. Limit all verbal interactions
Correct Answer: C
Rationale: Expressive aphasia impairs speech production. A whiteboard facilitates communication. Simple sentences help, but writing aids are critical, and loud speech or limiting interaction is unhelpful.
A 1000-mL dose of D5W 1/2 normal saline is to be infused in 8 hours. The drop factor for the tubing is 60 gtt/min. How many drops per minute should the nurse administer?
- A. 75 gtt/min
- B. 100 gtt/min
- C. 125 gtt/min
- D. 150 gtt/min
Correct Answer: C
Rationale: 125 gtt/min.