Nokea
A client at a psychiatric hospital tells the nurse that he does not want to join the others for dinner in the dining room because he already ate. The nurse is aware this client has been diagnosed with avoidant personality disorder. The best response from the nurse is to
- A. ask the client what would make group dinners more enjoyable so he will participate in the future.
- B. allow the client to skip the group dinner this time only.
- C. ask the client why he ate dinner so early.
- D. state clearly that the client is expected in the dining room and then walk with the client to the dining room.
Correct Answer: D
Rationale: Avoidant personality disorder involves social withdrawal due to fear of rejection. Gently encouraging participation while providing support (walking with the client) promotes socialization without confrontation.
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A client is receiving hospice and palliative care, including analgesia and other comfort measures. Which of the following indicates the client is undergoing life review? Select all that apply.
- A. The client looks through old photo albums.
- B. The client states that her analgesia is not adequate.
- C. The client reminisces about her children when they were young and her parenting skills.
- D. The client states that she is ready to die.
- E. The client states she does not want her children to have a funeral for her.
Correct Answer: A,C
Rationale: Looking at photos (A) and reminiscing about parenting (C) indicate life review, reflecting on past experiences. Other statements (B, D, E) relate to pain or end-of-life wishes.
The physician has prescribed a Becloforte (beclomethasone) inhaler two puffs twice a day for a client with asthma. The nurse should tell the client to report:
- A. Increased weight
- B. A sore throat
- C. Difficulty in sleeping
- D. Changes in mood
Correct Answer: B
Rationale: A sore throat may indicate oral candidiasis, a side effect of inhaled corticosteroids like beclomethasone.
The doctor has ordered 80 mg of furosemide (Lasix) two times per day. The nurse notes the patient's potassium level to be 2.5 meq/L. The nurse should:
- A. Administer the Lasix as ordered
- B. Administer half the dose
- C. Offer the patient a potassium-rich food
- D. Withhold the drug and call the doctor
Correct Answer: D
Rationale: A potassium level of 2.5 mEq/L is dangerously low; withholding Lasix and notifying the doctor prevents further potassium loss.
A 9-year-old is admitted with suspected rheumatic fever. Which finding is suggestive of Sydenham's chorea?
- A. Irregular movements of the extremities and facial grimacing
- B. Painless swellings over the extensor surfaces of the joints
- C. Faint areas of red demarcation over the back and abdomen
- D. Swelling, inflammation, and effusion of the joints
Correct Answer: A
Rationale: Sydenham's chorea, a manifestation of rheumatic fever, is characterized by irregular, involuntary movements and facial grimacing.
The nurse in the emergency department is responsible for the triage of four recently admitted clients. Which client should the nurse send directly to the treatment room?
- A. A 23-year-old female complaining of headache and nausea
- B. A 76-year-old male complaining of dysuria
- C. A 56-year-old male complaining of exertional shortness of breath
- D. A 42-year-old female complaining of recent sexual assault
Correct Answer: C
Rationale: Exertional shortness of breath may indicate a cardiac or respiratory emergency, requiring immediate attention.