Nokea
A client is brought to the emergency room following a motor vehicle accident. When assessing the client one-half hour after admission, the nurse notes several physical changes. Which finding would require the nurse's immediate attention?
- A. increased restlessness
- B. tachycardia
- C. tracheal deviation
- D. tachypnea
Correct Answer: C
Rationale: tracheal deviation. The deviated trachea is a sign that a mediastinal shift has occurred. This is a medical emergency.
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The nurse on the mental health unit is talking with a client with schizophrenia. Which of the following statements by the client would indicate that the client is experiencing a delusion of reference?
- A. Did you hear that voice? It told me to kill my parent.
- B. I need to get rid of the bugs that are crawling under my skin.
- C. The song on the radio is a message sent to me in secret code.
- D. I will not drink the tap water. The aliens are trying to poison me.
Correct Answer: C
Rationale: A delusion of reference involves believing neutral events or objects (e.g., a song on the radio) have personal significance or hidden messages (C). Auditory hallucinations (A) involve hearing voices, not reference. Tactile hallucinations (B) involve false sensations, and persecutory delusions (D) involve belief in harm without reference to neutral stimuli.
An adult has started on continuous ambulatory peritoneal dialysis. Which nursing instruction is of highest priority?
- A. Explain the principles of osmosis and diffusion and how dialysis works
- B. Teach the client aseptic technique
- C. Plan to withhold all drugs during dialysis
- D. Encourage the client to eat a high-sodium, high-potassium diet
Correct Answer: B
Rationale: Aseptic technique is critical in peritoneal dialysis to prevent peritonitis, a serious complication. Understanding dialysis mechanics, withholding drugs, or diet are secondary.
The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended?
- A. Seizures
- B. Withdrawal
- C. Craving
- D. Marked tolerance
Correct Answer: B
Rationale: Withdrawal. Early withdrawal symptoms, including nausea and tremor, appear within hours of reducing alcohol intake.
The nurse is caring for a client with panic disorder who is reporting palpitations and intense feelings of fear. The client is shaking and hyperventilating. Which of the following actions would be a priority for the nurse to take?
- A. Assess the client for auditory and visual hallucinations.
- B. Administer a benzodiazepine to the client.
- C. Explore possible triggers for the episode with the client
- D. Remain in the room with the client.
Correct Answer: D
Rationale: Staying with the client (D) provides safety and reassurance, reducing fear and hyperventilation during a panic attack. Hallucinations (A) are not typical, medication (B) is secondary, and exploring triggers (C) is appropriate after stabilization.
The nurse is reviewing lifestyle and nutritional strategies to help cables symptoms in a client with newly diagnosed gastroesophageal reflux disease. Which strategies should the nurse include? Select all that apply.
- A. Choose foods that are low in fat
- B. Do not consume any foods containing dairy
- C. Eat three large meals a day and minimize snacking
- D. Limit or eliminate the use of alcohol and tobacco
- E. Try to avoid caffeine, chocolate, and peppermint
Correct Answer: A,D,E
Rationale: GERD management focuses on reducing esophageal irritation. Low-fat foods (A) reduce gastric acid secretion and reflux risk. Limiting alcohol and tobacco (D) prevents lower esophageal sphincter relaxation and mucosal irritation. Avoiding caffeine, chocolate, and peppermint (E) minimizes sphincter relaxation. Dairy (B) is not universally contraindicated unless lactose intolerance is present. Large meals (C) increase gastric pressure, worsening reflux.