Nokea
A client recently lost a child due to poisoning. The client tells the nurse, 'I don't want to make any new friends right now.' This is an example of which of the following indicators of stress?
- A. emotional behavioral indicator
- B. spiritual indicator
- C. sociocultural indicator
- D. intellectual indicator
Correct Answer: C
Rationale: The client's withdrawal from forming new relationships reflects a sociocultural indicator of stress, as it affects social interactions. Emotional behavioral indicators involve mood changes, spiritual indicators relate to existential concerns, and intellectual indicators involve cognitive difficulties.
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A client receives a cervical intracavity radium implant as part of her therapy. A common side effect of a cervical implant is:
- A. creamy, pink-tinged vaginal drainage.
- B. stomatitis.
- C. constipation.
- D. xerostomia.
Correct Answer: A
Rationale: Creamy, pink-tinged vaginal drainage persists for 1 to 2 months after removal of a cervical implant.
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 client who recently lost 50 pounds just received news that she is pregnant. A possible nursing diagnosis is:
- A. Actual Chronic Low Self-Esteem (related to obesity).
- B. Potential Chronic Low Self-Esteem (related to obesity).
- C. Actual Situational Low Self-Esteem (related to fear of weight regain and pregnancy).
- D. Potential Situational Low Self-Esteem (related to fear of weight regain and pregnancy).
Correct Answer: D
Rationale: If there are indications of a body image disturbance, the nursing care plan should include body disturbances, related to a functional or physical problem. The disturbance might be an anticipated one - that is, weight gain and pregnancy. Stressors can include a change in physical appearance, sexuality concerns, or an unrealistic ideal self.
The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for:
- A. elevated blood pressure.
- B. Cheyne-Stokes respiration.
- C. elevated pulse rate.
- D. decreased temperature.
Correct Answer: B
Rationale: Cheyne-Stokes respirations are rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea, often associated with cardiac failure. This can be a sign of impending death.
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.