Nokea
A client was admitted to the psychiatric unit with major depression after a suicide attempt. In addition to feeling sad and hopeless, the nurse would assess for
- A. Anxiety, unconscious anger, and hostility
- B. Guilt, indecisiveness, poor self-concept
- C. Psychomotor retardation or agitation
- D. Meticulous attention to grooming and hygiene
Correct Answer: C
Rationale: Psychomotor retardation or agitation. These are common physiologic symptoms of depression.
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The nurse is administering a tuberculin skin test. How should the nurse insert the needle when administering the skin test?
- A. At a 10-degree angle
- B. At a 30-degree angle
- C. At a 60-degree angle
- D. At a 90-degree angle
Correct Answer: A
Rationale: A tuberculin skin test requires intradermal injection at a 10-degree angle to form a wheal under the skin. Other angles are used for subcutaneous or intramuscular injections.
The nurse manager has been using a block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that this method will
- A. Improve the quality of care
- B. Decrease staff turnover
- C. Minimize the amount of overtime payouts
- D. Improve team morale
Correct Answer: D
Rationale: Nurses are more satisfied when opportunities exist for autonomy and control. Self-scheduling improves team morale by giving staff more control over their work schedules.
A client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible.
When the nurse assesses the incision of a client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible. Which of these actions should the nurse take FIRST?
- A. Cover the open area with sterile gauze soaked in normal saline.
- B. Reapply a sterile dressing after cleaning the incision with peroxide.
- C. Pack the opened area with sterile 3/4-inch gauze soaked in normal saline.
- D. Apply Neosporin ointment and cover the incision with Tegaderm dressing.
Correct Answer: A
Rationale: Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) correct-evisceration is treated immediately by application of sterile gauze soaked in sterile normal saline, followed by notification of physician (2) not correct response to this complication (3) not correct response to this complication (4) not correct response to this complication
A client in labor is receiving magnesium sulfate IV.
Which assessment is MOST important to give during report to the nurse on the next shift?
- A. Respiratory rate changed from 13/min to 15/min.
- B. Increase in anxiety and hyperactivity.
- C. Presence of nausea and refusal to take clear liquids.
- D. Urine output decreased from 60 cc/h to 40 cc/h.
Correct Answer: D
Rationale: Strategy: Determine how each answer choice relates to magnesium sulfate. (1) not a concern because the respirations are increasing (2) not relevant to the medication (3) not relevant to the medication (4) correct-magnesium sulfate is a central nervous system depressant; side effect is oliguria
An adult male calls his nurse neighbor and says he is having severe chest pain and feels as though something terrible is happening to him. He rates his pain as 10 on the 10-point scale. In addition to calling 911, what should the nurse recommend the man do now?
- A. Take an aspirin
- B. Lie flat
- C. Take some deep breaths
- D. Go to bed
Correct Answer: A
Rationale: Aspirin reduces clot formation in suspected myocardial infarction, improving outcomes, and should be taken immediately.