Nokea
A long-term goal for the nurse in planning care for a depressed, suicidal client would be to:
- A. Provide him with a safe and structured environment.
- B. Assist him to develop more effective coping mechanisms.
- C. Have him sign a 'no-suicide' contract.
- D. Isolate him from stressful situations that may precipitate a depressive episode.
Correct Answer: B
Rationale: This statement represents a short-term goal. Long-term therapy should be directed toward assisting the client to cope effectively with stress. Suicide contracts represent short-term interventions. This statement represents an unrealistic goal. Stressful situations cannot be avoided in reality.
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A client is admitted to the emergency room with a gunshot wound to the right arm. After dressing the wound and administering the prescribed antibiotic, the nurse should:
- A. Ask the client if he has any medication allergies.
- B. Check the client's immunization record.
- C. Apply a splint to immobilize the arm.
- D. Administer medication for pain.
Correct Answer: C
Rationale: Immobilizing the arm with a splint is critical to prevent further damage to the injured area, reduce pain, and promote healing. Asking about allergies should have been done prior to administering antibiotics, checking immunization records is not a priority in this acute situation, and pain medication, while important, is secondary to stabilizing the injury.
The nurse is assessing breath sounds in a bronchovesicular client. She should expect that:
- A. Inspiration is longer than expiration
- B. Breath sounds are high pitched
- C. Breath sounds are slightly muffled
- D. Inspiration and expiration are equal
Correct Answer: D
Rationale: Inspiration is normally longer in vesicular areas. High-pitched sounds are normal in bronchial area. Muffled sounds are considered abnormal. Inspiration and expiration are equal normally in this area, and sounds are medium pitched.
Place in correct sequence the steps from 1-7 used when performing tracheostomy suctioning.
- A. Suction the oral cavity.
- B. Auscultate breath sounds for effectiveness.
- C. Set suction control at 80-120 mm Hg.
- D. Ambu or oxygenate at 100% O2
- E. Apply suction while withdrawing the suction catheter.
- F. Turn the head toward the side to be suctioned.
- G. Auscultate breath sounds prior to suctioning.
Correct Answer: G, C, D, F, E, B, A
Rationale: Sequence: Auscultate breath sounds (G), set suction pressure (C), oxygenate (D), turn head (F), apply suction (E), auscultate post-suction (B), suction oral cavity (A) to clean.
A client with Addison's disease has been receiving glucocorticoid therapy. Which finding indicates a need for dosage adjustment?
- A. Dryness of the skin and mucus membranes
- B. Dizziness when rising to a standing position
- C. A weight gain of six pounds in the past week
- D. Difficulty in remaining asleep
Correct Answer: C
Rationale: Rapid weight gain (6 pounds in a week) suggests fluid retention, a sign of glucocorticoid excess, requiring dosage adjustment. Dizziness may indicate underdosing, and the other symptoms are less specific.
The client is admitted with a diagnosis of postpartum endometritis. Which symptom is most likely to be present?
- A. Foul-smelling lochia
- B. Painless vaginal bleeding
- C. Decreased uterine tenderness
- D. Fetal distress
Correct Answer: A
Rationale: Postpartum endometritis a uterine infection typically causes foul-smelling lochia due to bacterial infection. Painful uterine tenderness is common painless bleeding suggests other causes and fetal distress is irrelevant postpartum.