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A client diagnosed with acute respiratory failure has an oral endotracheal tube attached to a mechanical ventilator and is about to begin the weaning process. The nurse determines that which item, that was previously used to minimize the client's anxiety, should now be limited?
- A. Radio
- B. Television
- C. Family visitors
- D. Antianxiety medications
Correct Answer: D
Rationale: Antianxiety medications and opioid analgesics are used cautiously in the client who is being weaned from a mechanical ventilator. These medications may interfere with the weaning process by suppressing the respiratory drive. The client may exhibit anxiety during the weaning process for a variety of reasons; therefore, distractions such as radio, television, and visitors are still very useful.
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The nurse is caring for a client whose family brought him to the hospital because they were worried about his personal safety. Which of the following statements by the client during the admission assessment indicates the need for immediate intervention by the nurse?
- A. Things are so bad that sometimes I don't know what to do make them better.
- B. My family normally supports my goals and helps me when I have a difficult time.
- C. I wish that everyone would leave me alone and quit trying to give me advice all the time.
- D. I keep a gun in my nightstand and sometimes I fall asleep holding it, trying to decide if I should pull the trigger or not.
Correct Answer: D
Rationale: This statement indicates active suicidal ideation with a plan and means, requiring immediate intervention to ensure safety.
The nurse is developed a teaching plan for a client prescribed spironolactone. On which psychosocial side effect of the medication should the nurse base the teaching plan?
- A. Edema
- B. Hair loss
- C. Weight loss
- D. Decreased libido
Correct Answer: D
Rationale: The nurse should be aware of the fact that the client taking spironolactone, a potassium-sparing diuretic, may experience body image changes that result from a threatened sexual identity. These are related to decreased libido, gynecomastia in males, and hirsutism in females. Edema, weight loss, and hair loss are not specifically associated with the use of this medication.
The nurse in the emergency department (ED) provides care for a client who states that the client's spouse, 'Became angry and physically abusive.' Which action does the nurse take first?
- A. Encourage the client to verbalize feelings.
- B. Assess the client for physical trauma.
- C. Provide a list of shelters appropriate for the situation.
- D. Assist the client to identify a support system.
Correct Answer: B
Rationale: Assessing for physical trauma is the priority to identify injuries requiring immediate medical attention, ensuring the client's safety. Verbalizing feelings, providing shelter lists, and identifying support systems are important but secondary to physical assessment.
The mental health nurse is caring for a client with Cluster B personality disorder. The nurse would expect the client to exhibit which behaviors? Select all that apply.
- A. suspicious of others, magical thinking, eccentric behavior, paranoia, relationship deficits
- B. preoccupation with rules and details, hoarding, ritualistic behavior, extremely devoted to work
- C. easily bored, poor and shallow interpersonal relationships, enjoys being the center of attention
- D. impulsivity, unpredictable behavior, extreme mood shifts, easily angered, playing people against each other
- E. suspicious and untrusting of others, argumentative, controlling of others, thoughts of grandiosity
Correct Answer: C,D
Rationale: Cluster B personality disorders (e.g., histrionic, borderline) involve attention-seeking, shallow relationships, impulsivity, and mood instability. Options A and E describe Cluster A, and B describes Cluster C.
The nurse is caring for an older client who has been placed in Buck's extension traction after a hip fracture. During the assessment of the client, the nurse notes that the client is disoriented. Which is the most appropriate nursing intervention for this client?
- A. Apply restraints to the client.
- B. Ask the family to stay with the client.
- C. Ask the laboratory to perform electrolyte studies.
- D. Reorient the client to time, place, and person frequently.
Correct Answer: D
Rationale: An inactive older person may become disoriented as a result of a lack of sensory stimulation. The appropriate nursing intervention would be to frequently reorient the client and place objects such as a clock and a calendar in the client's room to maintain orientation. Restraints may cause further disorientation and should not be applied unless specifically prescribed. Agency policies and procedures should be followed before the application of restraints. The family can assist with the orientation of the client, but it is not appropriate to ask the family to stay with the client. It is not within the scope of nursing practice to prescribe laboratory studies.