Nokea
A male client with an antisocial personality disorder is admitted to an inpatient mental health unit for multiple substance dependencies. When providing a history, the client justifies to the nurse his use of illicit drugs. Based on this pattern of behavior, this client's history is most likely to include which finding?
- A. Multiple convictions for misdemeanors and class B felonies.
- B. A history of stable employment
- C. Strong relationships with family members
- D. A pattern of seeking help when needed
Correct Answer: A
Rationale: The correct answer is A: Multiple convictions for misdemeanors and class B felonies. Clients with antisocial personality disorder often engage in behaviors that disregard societal rules and norms, leading to legal issues and criminal activities. This behavior is characteristic of individuals with antisocial personality disorder. Choices B, C, and D are incorrect because individuals with this disorder are less likely to have stable employment, strong family relationships, or seek help when needed due to their pattern of defiance and disregard for authority and rules.
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The nurse is reviewing a client's electrocardiogram and determines the PR interval (PRI) is prolonged. What does this finding indicate?
- A. Initiation of the impulses from a location outside the SA node
- B. Inability of the SA node to initiate an impulse at the normal rate
- C. Increased conduction time from the SA node to the AV junction
- D. Interference with the conduction through one or both ventricles
Correct Answer: C
Rationale: When the PR interval is prolonged, it signifies an increased conduction time from the SA node through the AV junction. This finding is characteristic of a first-degree heart block where there is a delay in the electrical conduction at the level of the AV node. Choices A, B, and D are incorrect as they do not accurately reflect the significance of a prolonged PR interval.
The nurse is assessing a client with left-sided heart failure. Which assessment finding requires immediate intervention?
- A. Jugular venous distention
- B. Shortness of breath
- C. Crackles in the lungs
- D. Peripheral edema
Correct Answer: C
Rationale: In a client with left-sided heart failure, crackles in the lungs are a critical assessment finding that necessitates immediate intervention. Crackles indicate pulmonary congestion, a sign of worsening heart failure that requires prompt attention to prevent respiratory distress. Jugular venous distention, shortness of breath, and peripheral edema are also common in heart failure, but crackles specifically point to pulmonary involvement and the urgent need for intervention.
The nurse is caring for a client with a history of atrial fibrillation who is prescribed warfarin (Coumadin). Which laboratory value should the nurse monitor closely?
- A. Prothrombin time (PT)
- B. Hemoglobin level
- C. International Normalized Ratio (INR)
- D. Serum sodium level
Correct Answer: C
Rationale: The INR should be closely monitored in a client prescribed warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps determine if the client's blood is clotting appropriately. While prothrombin time (PT) is related to warfarin therapy, the INR is a more precise measure. Hemoglobin level and serum sodium level are not directly related to monitoring warfarin therapy.
An adult male who lives alone is brought to the Emergency Department by his daughter who found him unresponsive. Initial assessment indicated that the client has minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and ventilated. Which nursing intervention has the highest priority?
- A. Notify the client's minister of his condition.
- B. Determine if the client has an executed living will.
- C. Provide the family with information about palliative care.
- D. Discuss the possibility of organ donation with the family.
Correct Answer: B
Rationale: Verifying whether the client has an executed living will is crucial to ensuring that his treatment preferences are followed. In this critical situation, knowing the client's wishes regarding medical interventions is paramount. Options A, C, and D are not the highest priority as they do not directly address the immediate need to determine the client's treatment preferences.
A client with a history of chronic heart failure is admitted with shortness of breath and crackles in the lungs. Which intervention should the nurse implement first?
- A. Administer oxygen therapy as prescribed.
- B. Administer a loop diuretic as prescribed.
- C. Administer intravenous morphine as prescribed.
- D. Obtain an arterial blood gas (ABG) sample.
Correct Answer: A
Rationale: Administering oxygen therapy is the priority intervention for a client with chronic heart failure presenting with shortness of breath and crackles in the lungs. Oxygen therapy helps improve oxygenation, which is crucial in managing respiratory distress. Loop diuretics (Choice B) may be indicated to manage fluid overload in heart failure but are not the immediate priority in this case. Administering morphine (Choice C) is not the first-line intervention for shortness of breath in heart failure and should be considered after addressing oxygenation and underlying causes. Obtaining an arterial blood gas sample (Choice D) can provide valuable information but is not the initial action needed to address the client's acute respiratory distress.