Nokea
A client admitted to the psychiatric unit claims to be the 'Son of God' and insists that he will not be confined by 'mere mortals.' The most likely explanation for the client's delusions is:
- A. A religious conversion
- B. A stressful event
- C. Low self-esteem
- D. Overwhelming anxiety
Correct Answer: C
Rationale: Delusions of grandeur, like claiming to be the 'Son of God,' often stem from low self-esteem, compensating with inflated self-perception. Religious conversion, stress, or anxiety are less likely causes.
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A client who is receiving hydralazine (Apresoline) q6h has a blood pressure of 90/60.
Which of the following nursing actions would be MOST appropriate?
- A. Withhold the medication.
- B. Check the urinary output.
- C. Administer the medication.
- D. Increase the potassium intake.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Is there an appropriate assessment? No. Determine the outcome of the implementations. (1) correct-BP of 90/60 is too low for an additional dose of medication, withholding the medication and checking with the doctor is appropriate (2) assessment, appropriate nursing action for a client on an antihypertensive that has diuretic effects due to increased blood flow to the kidney, not a priority in this instance (3) unnecessary (4) appropriate nursing action for a client on an antihypertensive that has diuretic effects due to increased blood flow to the kidney, not a priority in this instance
Following hip replacement surgery, an elderly client is ordered to begin ambulation with a walker.
Which of the following statements by the nurse is BEST?
- A. Sit in a low chair for ease in getting up to use the walker.
- B. Make sure rubber caps are in place on all four legs of the walker.
- C. You will begin weight-bearing on the affected hip soon.
- D. Practice tying your own shoes before you begin ambulating.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks (2) correct-intact rubber caps should be present on walker legs to prevent accidents (3) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks (4) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks
A client with clotting disorder has an order to continue Lovenox (Enoxaparin) injections after discharge. In assessing the client's readiness for teaching, the most important factor for the nurse to assess is the client's:
- A. Prior knowledge of anticoagulants and their role in controlling his disease
- B. Willingness to learn about injection techniques and site selection
- C. Adaptation to the need for daily injections to control his symptoms
- D. Overall intelligence and developmental level
Correct Answer: B
Rationale: Willingness to learn is critical for effective teaching about self-administering injections. Knowledge, adaptation, and intelligence are secondary.
The nurse is teaching a client with a new diagnosis of gout about allopurinol (Zyloprim). Which of the following statements by the client indicates a need for further teaching?
- A. I should drink plenty of water while taking this medication.
- B. I should report a rash to my doctor.
- C. I should take this medication with food.
- D. I should stop this medication if my gout attacks stop.
Correct Answer: D
Rationale: Stopping allopurinol when gout attacks stop is incorrect, as it is used long-term to prevent uric acid buildup. Options A, B, and C are correct: water prevents kidney stones, rash may indicate hypersensitivity, and food reduces GI upset.
An eight-year-old with cystic fibrosis (CF).
Which of the following dietary requirements should be considered?
- A. High protein, high fat, and high calories.
- B. High protein, low fat, and high calories.
- C. Low protein, low fat, and low carbohydrate.
- D. High protein, high fat, and low carbohydrate.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) contains high fat (2) correct-impaired inTest inal absorption due to cystic fibrosis necessitates a diet higher in protein and calories; fat is decreased because it may interfere with absorption of other nutrients (3) not adequate for this child (4) contains high fat