Nokea
A client has been diagnosed with depression, and a nurse is assisting them. Which of the following is an example of a short-term outcome as part of the nursing process for this client?
- A. Client will verbalize that depression symptoms have lifted
- B. Client will identify life stressors that may be contributing to depression
- C. Client's insomnia will be resolved as evidenced by 8 hours of sleep each night
- D. Client will identify a mental health counselor in the community with whom they can meet for ongoing therapy
Correct Answer: B
Rationale: In the nursing process for a client with depression, short-term outcomes are goals that need to be achieved before advancing towards long-term outcomes. Identifying life stressors that may be contributing to the depression is a crucial initial step. This process helps the client work through feelings of grief or sadness before moving on to long-term goals like therapy and depression management.
Choice A is not a short-term outcome as the lifting of depression symptoms is usually a long-term goal. Choice C focuses on resolving insomnia, which is a symptom of depression, but not directly addressing the root cause. Choice D involves identifying a mental health counselor for ongoing therapy, which is more aligned with a long-term treatment plan, rather than a short-term outcome.
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An increase in the neurotransmitter dopamine is associated with which of the following illnesses?
- A. Schizophrenia
- B. Depression
- C. Alzheimer's disease
- D. Anxiety
Correct Answer: A
Rationale: An increase in the neurotransmitter dopamine is associated with schizophrenia. Dopamine dysregulation is linked to some symptoms of schizophrenia, such as hallucinations and delusions. Depression (choice B) is more commonly associated with abnormalities in serotonin and norepinephrine. Alzheimer's disease (choice C) is primarily characterized by deficits in acetylcholine and other neurotransmitters. Anxiety disorders (choice D) are often linked to imbalances in neurotransmitters like serotonin, norepinephrine, and GABA, rather than dopamine.
Which of the following is an example of an opioid?
- A. Mescaline
- B. Diazepam
- C. Phenobarbital
- D. Methadone
Correct Answer: D
Rationale: Opioids are a type of drug classified as narcotics. Nurses working with clients with substance abuse issues often encounter opioids. Opioids have the potential for addiction. Examples of opioids include methadone, codeine, morphine, and hydromorphone. Mescaline (Choice A) is a hallucinogen, not an opioid. Diazepam (Choice B) is a benzodiazepine used to treat anxiety and other conditions, not an opioid. Phenobarbital (Choice C) is a barbiturate used to treat seizures and insomnia, not an opioid.
During a discussion about glaucoma at the community center, which comment by one of the retirees would the nurse give a supportive comment to reinforce correct information?
- A. I usually avoid driving at night since lights sometimes seem to make things blur.''
- B. I take half of the usual dose for my sinuses to maintain my blood pressure.''
- C. I have to sit at the side of the pool with the grandchildren since I can't swim with this eye problem.''
- D. I take extra fiber and drink lots of water to avoid getting constipated.''
Correct Answer: D
Rationale: The correct answer is ''I take extra fiber and drink lots of water to avoid getting constipated.'' In individuals with glaucoma, activities that involve straining, such as constipation, should be avoided as they can increase intraocular pressure. Choices A, B, and C are incorrect as they do not align with the management of glaucoma. Driving at night or taking sinus medication are not directly related to glaucoma, and sitting by the pool due to an eye problem does not provide information relevant to managing glaucoma.
A client experiences postpartum hemorrhage eight hours after the birth of twins. Following administration of IV fluids and 500 ml of whole blood, her hemoglobin and hematocrit are within normal limits. She asks the nurse whether she should continue to breastfeed the infants. Which of the following is based on sound rationale?
- A. Nursing will help contract the uterus and reduce your risk of bleeding.
- B. Breastfeeding twins will take too much energy after the hemorrhage.
- C. The blood transfusion may increase the risks to you and the babies.
- D. Lactation should be delayed until the 'real milk' is secreted.
Correct Answer: A
Rationale: The correct answer is 'Nursing will help contract the uterus and reduce your risk of bleeding.' Stimulation of the breast during nursing releases oxytocin, which contracts the uterus. This contraction is especially important following hemorrhage. Choice B is incorrect because breastfeeding can actually help prevent further bleeding by promoting uterine contractions. Choice C is incorrect as the blood transfusion is aimed at restoring the client's blood volume and should not significantly impact the babies. Choice D is incorrect as lactation should not be delayed, as breastfeeding can provide numerous benefits to both the mother and infants, including aiding in the prevention of postpartum hemorrhage.
When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled 'opened' and dated 48 hours prior to the current date. Which is the best action for the nurse to take?
- A. Discard the saline solution and obtain a new unopened bottle.
- B. Obtain a new sterile syringe to draw up the labeled saline solution.
- C. Use the saline solution and then relabel the bottle with the current date.
- D. Use the normal saline solution once more and then discard.
Correct Answer: A
Rationale: Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded. Options B and C are incorrect as they involve using the expired solution. Option A is incorrect as reusing the solution after it has been opened for more than 24 hours poses a risk of contamination. Therefore, the best course of action is to discard the expired solution and obtain a new unopened bottle for sterile wound care.