Nokea
A daughter is concerned that her mother is in denial when discussing her diagnosis of breast cancer because she sometimes says that breast cancer isn't that serious and changes the subject. The nurse informs the daughter that denial can be a healthy defense mechanism if it is used:
- A. To permit her mother to seek unconventional treatments.
- B. When making decisions about her care.
- C. Alone and not in combination with other defense mechanisms.
- D. To allow her mother to continue in her role as a mother.
Correct Answer: D
Rationale: Denial can be healthy if it allows the client to maintain normal roles (e.g., as a mother) while gradually processing the diagnosis, as long as it doesn't interfere with treatment.
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The client with peripheral vascular disease has been prescribed diltiazem (Cardizem). The nurse should determine the effectiveness of this medication by assessing the client for:
- A. Relief of anxiety
- B. Sedation
- C. Vasoconstriction
- D. Vasodilation
Correct Answer: D
Rationale: Diltiazem, a calcium channel blocker, promotes vasodilation in PVD, improving blood flow and reducing claudication symptoms. The nurse assesses for vasodilation (e.g., reduced pain, warmer extremities). It does not primarily relieve anxiety, cause sedation, or promote vasoconstriction.
The nurse is preparing to insert a peripheral vascular access device. Place the following actions in the order in which they need to be performed, starting from first to last.
- A. Apply sterile dressing over the intravenous site.
- B. Clean the selected area using an alcohol-based 2% chlorhexidine solution using friction for 30 seconds.
- C. Place the tourniquet 10 to 15 cm (4-6 inches) above the proposed site.
- D. Insert the intravenous catheter at a 15 to 30 degree angle.
- E. Advance the catheter until a flash of blood is seen, then advance the catheter into the vein while removing the needle.
- F. Palpate vein at intended insertion site by pressing downward.
- G. Release tourniquet temporarily.
Correct Answer: C,F,G,B,D,E
Rationale: The correct order ensures proper vein selection, site preparation, catheter insertion, and securement while minimizing complications.
The nurse is assessing a client with hepatitis and notices that the AST and ALT levels have increased. Which of the following statements by the client requires further instruction by the nurse?
- A. I require increased periods of rest.
- B. I follow a low-fat, high carbohydrate diet.
- C. I eat dry toast to relieve my nausea.
- D. I take acetaminophen (Tylenol) for arthritis pain.
Correct Answer: D
Rationale: Acetaminophen (D) is hepatotoxic and should be avoided in hepatitis due to increased liver enzyme levels. Rest (A), a low-fat, high-carbohydrate diet (B), and dry toast for nausea (C) are appropriate.
A 49-year-old male with a tracheostomy tube confides to the nurse during a clinic visit that he is beginning to avoid sexual activity because of the increased tracheostomy secretions. Which of the following statements by the nurse will be most helpful to the client?
- A. I have a special medication to decrease secretions.
- B. Avoid fluid intake 2 hours before sexual activity.
- C. Place a thin piece of gauze over the tracheostomy.
- D. Wash the tracheostomy area with deodorizing antibacterial soap before sexual activity.
Correct Answer: C
Rationale: Placing a thin gauze over the tracheostomy can absorb secretions, reducing embarrassment and enabling the client to engage in sexual activity comfortably.
Which of the following terms describes the condition of a client with the disease in dosage to maintain adequate analgesia?
- A. Pseudoaddiction.
- B. Physical dependence.
- C. Psychological dependence.
- D. Drug tolerance.
Correct Answer: D
Rationale: Drug tolerance occurs when a client requires increased doses to maintain analgesia due to the body's adaptation to the medication.