Nokea
A client continually repeats phrases that others have just said. The nurse recognizes this behavior as:
- A. Autistic.
- B. Ecopraxic.
- C. Echolalic.
- D. Catatonic.
Correct Answer: C
Rationale: Echolalia is the repetition of words or phrases heard from others.
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What is the priority nursing action for this patient?
- A. Obtain an order for a blood alcohol level
- B. Contact the family to obtain additional history and baseline information
- C. Administer naloxone (Narcan) 2-4 mg as ordered
- D. Administer IV fluid support with supplemental thiamine as ordered
Correct Answer: D
Rationale: Fluid support and thiamine administration address potential dehydration and nutritional deficits in intoxicated patients.
Why might a client receive a central venous catheter?
- A. Client is receiving 0.9 normal saline
- B. Client is receiving total parenteral nutrition (TPN)
- C. Client is receiving short-term IV therapy
- D. Client has had one infiltrated IV
Correct Answer: B
Rationale: The correct answer is B because TPN requires a central venous catheter due to the high osmolarity of the solution.
The most important laboratory value to monitor in a patient with heavy bleeding due to fibroids is:
- A. Hemoglobin
- B. Luteinizing hormone
- C. White blood cell count
- D. Potassium
Correct Answer: A
Rationale: Hemoglobin levels are critical to assess the severity of blood loss and anemia in patients with heavy bleeding.
When assessing a client with a pneumothorax and a chest tube, which finding should the nurse notify the provider about?
- A. Movement of the trachea toward the unaffected side
- B. Bubbling of the water in the water seal chamber with exhalation
- C. Crepitus in the area above and surrounding the insertion site
- D. Eyelets not visible
Correct Answer: A
Rationale: Step 1: Movement of the trachea toward the unaffected side indicates tension pneumothorax, a life-threatening condition requiring immediate intervention.
Step 2: This finding can lead to compromised breathing and hemodynamic instability if not addressed promptly.
Step 3: B: Bubbling in the water seal chamber with exhalation is expected in a properly functioning chest tube system.
Step 4: C: Crepitus at the insertion site is common due to air entering subcutaneous tissue during tube placement and is not an urgent concern.
Step 5: D: Eyelets not visible can indicate dislodgement but is not as critical as tracheal deviation in this scenario.
To improve Mr. Puff’s breathing pattern, the nurse can
- A. Encourage coughing and deep breathing
- B. Provide nasal O₂ at 6 L/min
- C. Sit him in a chair
- D. Teach him pursed-lip breathing
Correct Answer: D
Rationale: Pursed-lip breathing improves oxygenation and reduces shortness of breath.