Nokea
A nurse assigned to a manipulative client for 5 days becomes aware of feelings of reluctance to interact with the client. The next action by the nurse should be to
- A. Discuss the feeling of reluctance with an objective peer or supervisor
- B. Limit contacts with the client to avoid reinforcement of the manipulative behavior
- C. Confront the client about the negative effects of behaviors on other clients and staff
- D. Develop a behavior modification plan that will promote more functional behavior
Correct Answer: A
Rationale: The nurse who experiences stress in the therapeutic relationship can gain objectivity through supervision. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse-client relationship.
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An adult has the following blood gasses: pH=7.52, pCO2=50, HCO3=35, and pO2=90. What is most likely to be in the client's history of presenting signs and symptoms?
- A. Persistent diarrhea
- B. Frequent vomiting
- C. Anxiety attack
- D. Emphysema
Correct Answer: B
Rationale: High pH and HCO3 indicate metabolic alkalosis, commonly caused by frequent vomiting, losing gastric acid.
The nurse is teaching a client with a new diagnosis of rheumatoid arthritis about hydroxychloroquine (Plaquenil). Which of the following statements by the client indicates a need for further teaching?
- A. I should report vision changes to my doctor.
- B. I should take this medication with food.
- C. I should have regular eye exams.
- D. I should stop this medication if my joints feel better.
Correct Answer: D
Rationale: Stopping hydroxychloroquine when joints feel better is incorrect, as rheumatoid arthritis requires ongoing treatment to prevent flares. Options A, B, and C are correct: vision changes may indicate retinal toxicity, food reduces GI upset, and eye exams monitor for toxicity.
The nurse is assisting the physician with the insertion of a central venous catheter. Which statement best explains the rationale for placing the client in Trendelenburg position?
- A. It will make catheter insertion easier.
- B. It will make the client more comfortable.
- C. It will prevent ventricular tachycardia.
- D. It will prevent the development of pulmonary emboli.
Correct Answer: A
Rationale: Trendelenburg position elevates the veins, making central venous catheter insertion easier. Comfort , tachycardia , and emboli are not primary concerns.
The nurse is caring for a 78-year-old woman in a long-term care facility. The client is sitting in a geriatric chair with the attached tray in place. The client is agitated and appears to be sliding down in the chair. What is the best action for the nurse to take?
- A. Ask the supervisor for advice
- B. Put a jacket restraint on the client
- C. Tie a sheet around the client's waist
- D. Use foam wedges beside the client
Correct Answer: D
Rationale: Foam wedges stabilize the client safely and comfortably, preventing sliding without restrictive measures. Restraints (jacket or sheet) increase agitation and risk, and consulting the supervisor delays action.
An adult client became incontinent while hospitalized. The client now drinks very little. The nurse understands that this is:
- A. a coping strategy.
- B. a defense mechanism.
- C. a way to not bother the nurse.
- D. regression.
Correct Answer: A
Rationale: Reduced fluid intake is a coping strategy to avoid incontinence, though it risks dehydration, reflecting an attempt to manage embarrassment.