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A client reports to the nurse that the voices are practically nonstop and that he needs to leave the hospital immediately to find his girlfriend and kill her. The best verbal response to the client by the nurse at this time is:
- A. I understand that the voices are real to you, but I want you to know I don't hear them. They are a symptom of your illness.'
- B. Just don't pay attention to the voices. They'll go away after some medication.'
- C. You can't leave here. This unit is locked and the doctor has not ordered your discharge.'
- D. We will have to put you in seclusion and restraints for a while. You could hurt someone with thoughts like that.'
Correct Answer: A
Rationale: This response validates the client's experience and presents reality to him. This nontherapeutic response minimizes and dismisses the client's verbalized experience. This response can be interpreted by a paranoid client as a threat, thereby increasing the client's potential for violence and loss of control. This response is also threatening. The client's behavior does not call for restraints because he has not lost control or hurt anyone. If seclusion or restraints were indicated, the nurse should never confront the client alone.
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A child with croup is placed in a cool, high-humidity tent connected to room air. The primary purpose of the high-humidity tent is to:
- A. Prevent insensible water loss
- B. Provide a moist environment with oxygen at 30%
- C. Prevent dehydration and reduce fever
- D. Liquefy secretions and relieve laryngeal spasm
Correct Answer: D
Rationale: High-humidity tents in croup moisten airways, liquefying secretions and relieving laryngeal spasms, easing breathing. Oxygen levels are not necessarily 30%, and dehydration or fever is secondary.
The most appropriate method of evaluating whether the diet of a child with cystic fibrosis is meeting his caloric needs is:
- A. Careful monitoring of weight loss or gain
- B. Carefully recording amounts and types of foods ingested
- C. Keeping a strict account of the number of calories ingested
- D. Keeping a careful account of the amount of pancreatic enzymes ingested
Correct Answer: A
Rationale: Consistent weight gain, even if it is slow, is an indication that the child is eating and digesting sufficient calories.
Place in sequence from 1-5 the proper order for introducing items to the infant's diet.
- A. Strained meats
- B. Whole milk
- C. Rice cereal
- D. Fruits
- E. Vegetables
Correct Answer: C, D, E, A, B
Rationale: Infant diet sequence: rice cereal (C) at 6 months, then fruits (D) and vegetables (E), strained meats (A) around 7-8 months, and whole milk (B) after 12 months.
A home health nurse has several elderly clients in her case load. Which of the following clients ~(is most likely to be a victim of elder abuse?
- A. A 76-year-old female with Alzheimer's dementia
- B. A 70-year-old male with diabetes mellitus
- C. A 64-year-old female with a hip replacement
- D. A 72-year-old male with Parkinson's disease
Correct Answer: A
Rationale: Elderly clients with Alzheimer's dementia are at highest risk for abuse due to cognitive impairment, dependency, and potential caregiver stress. The other conditions pose less risk.
A client is having a pneumonectomy done today, and the nurse is planning her postoperative care. Nursing interventions for a postoperative left pneumonectomy would include:
- A. Monitoring the chest tubes
- B. Positioning the client on the right side
- C. Positioning the client in semi-Fowler position with a pillow under the shoulder and back
- D. Monitoring the right lung for an increase in rales
Correct Answer: D
Rationale: Monitoring the right lung for an increase in rales is essential to detect early signs of fluid accumulation or infection in the remaining lung.