Nokea
A client admitted to the psychiatric unit claims to be the Pope and insists that he will not be kept away from his followers. The most likely explanation for the client's delusion is:
- A. A reaction formation
- B. A stressful event
- C. Low self-esteem
- D. Overwhelming anxiety
Correct Answer: C
Rationale: Delusions of grandeur, like claiming to be the Pope, often stem from low self-esteem in psychiatric disorders like schizophrenia, compensating for feelings of inadequacy. The other factors are less specific.
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The nurse is caring for a client with a history of a stroke who has hemiparesis. The nurse should:
- A. Position the client on the strong side
- B. Encourage passive range of motion
- C. Provide a high-protein diet
- D. Use a sling for the affected arm
Correct Answer: D
Rationale: A sling supports the affected arm in hemiparesis, preventing subluxation. Positioning varies, passive motion is secondary, and diet depends on needs.
A physician's order reads: Administer furosemide oral solution 0.5 mL stat. The furosemide bottle dosage is 10 mg/mL. What dosage of furosemide should the nurse give to this infant?
- A. 5 mg
- B. 0.5 mg
- C. 0.05 mg
- D. 20 mg
Correct Answer: A
Rationale: 1 mg = 0.1 mL, then 0.5 mL X = 5 mg.
A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:
- A. Decreased blood pressure and constricted pupils
- B. Increased heart rate and increased respirations
- C. Increased respirations and increased blood pressure
- D. Anoxia and absence of the cough reflex
Correct Answer: A
Rationale: Cholinergic crisis, often from excessive anticholinesterase medication, causes parasympathetic overstimulation, leading to decreased blood pressure and constricted pupils.
The nurse would need to monitor the serum glucose levels of a client receiving which of the following medications, owing to its effects on glycogenolysis and insulin release?
- A. Norepinephrine (Levophed)
- B. Dobutamine (Dobutrex)
- C. Propranolol (Inderal)
- D. Epinephrine (Adrenalin)
Correct Answer: D
Rationale: Norepinephrine's side effects are primarily related to safe, effective care environment and include decreased peripheral perfusion and bradycardia. Dobutamine's side effects include increased heart rate and blood pressure, ventricular ectopy, nausea, and headache. Propranolol's side effects include elevated blood urea nitrogen, serum transaminase, alkaline phosphatase, and lactic dehydrogenase. Epinephrine increases serum glucose levels by increasing glycogenolysis and inhibiting insulin release. Prolonged use can elevate serum lactate levels, leading to metabolic acidosis, increased urinary catecholamines, false elevation of blood urea nitrogen, and decreased coagulation time.
A 19-year-old male client arrived via ambulance to the emergency room following a motorcycle accident. He is comatose. His face has evidence of dried blood. On assessment, the nurse notes an obvious injury to his left eye. The preferred positioning for a client with an obvious eye injury is:
- A. Reclining to control bleeding
- B. Any position in which the client is comfortable
- C. Side-lying, either left or right
- D. Sitting with head support
Correct Answer: D
Rationale: A reclining position can cause a penetrating object to advance further into the eye. Prevention of further injury is the priority, not comfort. A side-lying position may increase intraocular and intracranial pressure if an accompanying head injury is suspected. A sitting position with the head supported will prevent further injury while allowing injury care to take place.