Nokea
A client with a diagnosis of nephrotic syndrome states to the nurse, 'Why should I even bother trying to control my diet and the swelling? It doesn't really matter what I do if I can never get rid of this kidney problem anyway!' Which potential client problem should the nurse address based on the client's statement?
- A. Anxiety
- B. Difficulty coping
- C. Feeling powerless
- D. Negative body image
Correct Answer: C
Rationale: Feeling powerless is a problem when the client believes that personal actions will not affect an outcome in any significant way. Anxiety occurs when the client has a feeling of unease with a vague or undefined source. Difficulty coping indicates that the client has impaired adaptive abilities or behaviors in meeting the demands or roles expected from the individual. Negative body image occurs when the way the client perceives body image is altered.
You may also like to solve these questions
Which manifestations associated with thyroid storm indicate the need for immediate nursing intervention?
- A. Polyuria, nausea, and severe headaches
- B. Polydipsia, translucent skin, and obesity
- C. Fever, tachycardia, and systolic hypertension
- D. Profuse diaphoresis, flushing, and constipation
Correct Answer: C
Rationale: The excessive amounts of thyroid hormone cause a rapid increase in the metabolic rate, thereby causing the manifestations of thyroid storm such as fever, tachycardia, and hypertension. When these signs present themselves, the nurse must take quick action to prevent deterioration of the client's health because death can ensue. Priority interventions include maintaining a patent airway and stabilizing the hemodynamic status. The remaining options do not indicate the need for immediate nursing intervention nor are they associated with thyroid storm.
A client on a psychiatric care unit approaches the nurse and complains of muscle spasms in his neck, stiffness in other muscles, and that his eyes are rolling upward. The client had two p.r.n. doses of haloperidol (Haldol) in the last 6 hours. Of the drugs that have been ordered for the client as needed (see chart), the nurse should administer:
- A. Lorazepam (Ativan).
- B. Amantadine (Symmetrel).
- C. Diphenhydramine (Benadryl).
- D. Benztropine (Cogentin).
Correct Answer: D
Rationale: Dystonic adverse effects of haloperidol, especially oculogyric crises, are painful and frightening. I.M. benztropine is the fastest and most effective drug for managing dystonia. Lorazepam is an antianxiety medication and is not effective for treatment of dystonia. Although amantadine and diphenhydramine can be used for extrapyramidal symptoms, oral medications do not work as quickly, and amantadine may worsen psychotic symptoms.
Which of the following is an effective security plan that you may most likely want to consider for implementation within your facility?
- A. Training all nurses to serve as a part of a security response team
- B. Training all clerical staff to be a part of a security response team
- C. The restriction of visitors in a special care area
- D. Bar coded client identification bands to insure proper identification
Correct Answer: C,D
Rationale: Restricting visitors in special care areas and using bar-coded client identification bands are effective security measures to enhance safety and protect client identity, respectively.
A client is prescribed diphenhydramine 1% as a topical agent for allergic dermatosis. The nurse evaluates that the medication is having the intended effect when the client reports relief of what complaint?
- A. Pain
- B. Urticaria
- C. Headache
- D. Skin redness
Correct Answer: B
Rationale: Diphenhydramine is an antihistamine medication that has many uses. When used as a topical agent on the skin, it reduces the symptoms of allergic reaction, such as itching or urticaria. It does not act to relieve pain, headache, or skin redness.
A nurse at the outpatient clinic receives a lithium level report of 1.0 mEq/L for a client who has been taking lithium for 2 months. The nurse should interpret this level to indicate which of the following?
- A. An error in reporting
- B. Too low to be therapeutic
- C. Too high, indicating toxicity
- D. Within the therapeutic range
Correct Answer: D
Rationale: A lithium level of 1.0 mEq/L is within the therapeutic range (0.6–1.2 mEq/L) for maintenance therapy. Levels below this are subtherapeutic, and higher levels indicate toxicity.