A client is admitted with a diagnosis of Multiple Drug Use. The nurse should plan care based on knowledge that:
- A. Multiple drug use is very uncommon
- B. People might use more than one drug to enhance the effect or relieve withdrawal symptoms
- C. Alcohol and barbiturates used together are not dangerous because one is a stimulant and the other is a depressant
- D. Assessment and intervention are easier with multiple drug use because of the synergistic effect
Correct Answer: B
Rationale: Multiple drug use is common to enhance effects or relieve withdrawal symptoms, complicating assessment and intervention due to varied drug interactions.
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A female having her first child is experiencing which type of crisis event?
- A. Situational
- B. Maturational
- C. Adventitious
- D. Reactive
Correct Answer: B
Rationale: Having a first child is a maturational crisis, requiring new coping strategies for the developmental transition to parenthood.
A nurse is screening patients for immunizations. Which of following is not a contraindication for immunization?
- A. Seizures
- B. Fever >3 days
- C. Malignancy >3 months
- D. Illness >6 months
Correct Answer: D
Rationale: Chronic conditions are not considered a contraindication for immunization.
A 64 year-old Alzheimer's patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure?
- A. Secure the restraints to the bed rails on all extremities.
- B. Notify the physician that restraints have been placed properly.
- C. Communicate with the patient and family the need for restraints.
- D. Position the head of the bed at a 45 degree angle.
Correct Answer: C
Rationale: Both the family and the patient should have the need for restraints explained to them.
When discussing possible complications of pregnancy with a client, the nurse should explain that all of the following are symptoms of urinary tract infection (UTI). Which of the following is least indicative of UTI during pregnancy?
- A. low-back pain
- B. urinary frequency
- C. GI distress
- D. malaise
Correct Answer: B
Rationale: Urinary frequency is least indicative of UTI during pregnancy because it is a common minor discomfort of pregnancy and is caused by pressure of the growing uterus on the bladder. As the uterus rises in the second trimester, there are no problems. Frequency returns in the third trimester when the uterus drops into the pelvic cavity. A UTI has the symptoms of frequency, back pain, supra pubic discomfort, and malaise and is diagnosed by laboratory findings.
A nurse is caring for a client with an elevated cortisol level. The nurse can expect the client to exhibit symptoms of:
- A. urinary excess.
- B. hyperpituitarism.
- C. urinary deficit.
- D. hyperthyroidism.
Correct Answer: C
Rationale: High levels of cortisol can produce sodium and fluid retention and potassium deficit, thus creating urinary deficit.