Nokea
A client tells the nurse, 'Everybody smiles at me because they know that I was chosen by God for this mission.' The nurse interprets this statement as which of the following?
- A. Idea of reference.
- B. Thought insertion.
- C. Visual hallucination.
- D. Neologism.
Correct Answer: A
Rationale: The statement reflects an idea of reference, where the client believes others' actions (smiling) are related to their special mission, a common delusion in psychiatric conditions.
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A client with a history of asthma is prescribed albuterol (Proventil). The nurse should instruct the client to:
- A. Use the inhaler daily to prevent attacks.
- B. Rinse the mouth after each use.
- C. Use the inhaler during an acute attack.
- D. Stop the inhaler if heart palpitations occur.
Correct Answer: C
Rationale: Albuterol is a rescue inhaler used during acute asthma attacks to relieve bronchospasm.
Which statement about referrals is accurate?
- A. Referrals complement the healthcare teams' abilities to provide optimal care to the client.
- B. Referrals simply allow the client to be discharged into the community with the additional care they need.
- C. Nurses facilitate referrals to only the resources within the facility.
Correct Answer: A
Rationale: Referrals enhance the healthcare team's ability to provide comprehensive care by connecting clients to specialized services, not limited to discharge or internal resources .
The nurse is developing an education plan for clients with hypertension. Which of the following long-term goals is most appropriate for the nurse to emphasize?
- A. Develop a plan to limit stress.
- B. Participate in a weight reduction program.
- C. Commit to regular exercise.
- D. Monitor blood pressure regularly.
Correct Answer: D
Rationale: Regular blood pressure monitoring empowers clients to track their hypertension and adjust lifestyle or medication as needed.
The nurse inserting an oropharyngeal airway into an assigned client should plan to use which insertion procedure?
- A. Flexing the client's neck
- B. Leaving dentures in place
- C. Suctioning the client's mouth only if prescribed
- D. Inserting the airway with the tip pointed upward
Correct Answer: D
Rationale: The airway is inserted with the tip pointed upward and is then rotated downward once the flange has reached the client's teeth. The client should be positioned supine, with the neck hyperextended if possible. Before insertion of an oropharyngeal airway, any dentures or partial plates should be removed from the client's mouth. After insertion, the client's mouth is suctioned every hour or as necessary. The airway is removed for inspection of the mouth every 2 to 4 hours.
A client with a history of breast cancer is admitted with bone metastases. The nurse should include which of the following in the plan of care?
- A. Administer bisphosphonates as prescribed.
- B. Restrict calcium intake.
- C. Encourage bed rest.
- D. Apply cold packs to affected areas.
Correct Answer: A
Rationale: Bisphosphonates reduce bone resorption and pain in bone metastases.