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A nurse in an acute mental health facility is creating a plan of care for a new client who has histrionic personality disorder. Which of the following is the highest priority for the nurse?
- A. Encourage client input in the treatment plan.
- B. Communicate with the client using concrete language.
- C. Demonstrate assertive behavior.
- D. Promote appropriate behavior during group therapy sessions.
Correct Answer: B
Rationale: The correct answer is B: Communicate with the client using concrete language. When working with a client with histrionic personality disorder, using concrete language helps to set clear boundaries and prevent misinterpretations. This is crucial in maintaining a therapeutic relationship and managing their behavior effectively. Encouraging client input (choice A) is important but not the highest priority in this case. Demonstrating assertive behavior (choice C) and promoting appropriate behavior in group therapy (choice D) are important but not as immediately crucial as clear communication.
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A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?
- A. A child whose parents answer questions for the child
- B. A child who has frequent visitors
- C. A child who has a BMI indicating obesity
- D. A child who uses the call light frequently
Correct Answer: A
Rationale: The correct answer is A. When parents answer questions for the child, it may indicate a lack of autonomy or control over their own care, suggesting potential abuse or neglect. This behavior can be a red flag for the nurse to further assess the child's situation. Choices B, C, and D do not necessarily indicate abuse. Frequent visitors could be a sign of social support, obesity may be due to various factors, and using the call light frequently may indicate medical needs rather than abuse. It is essential for the nurse to explore further if a child's autonomy is being compromised.
A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 8 g/dL and a hematocrit level of 28 g/dL. The nurse suspects which of the following types of anemia?
- A. Pernicious anemia
- B. Folic acid deficiency anemia
- C. Iron deficiency anemia
- D. Sickle cell anemia
Correct Answer: C
Rationale: The correct answer is C: Iron deficiency anemia. The client's low hemoglobin and hematocrit levels indicate a decrease in red blood cells, which is characteristic of anemia. Iron deficiency anemia is the most common type of anemia, typically caused by inadequate iron intake or absorption, leading to decreased production of hemoglobin. This results in symptoms like weakness, fatigue, and heavy menstrual periods, as seen in the client. Pernicious anemia (A) is due to vitamin B12 deficiency, not iron. Folic acid deficiency anemia (B) presents with similar symptoms but typically has normal iron levels. Sickle cell anemia (D) is a genetic disorder causing abnormal hemoglobin production, not related to iron deficiency.
While in group therapy,a nurse is caring for a client who has cancer and is scheduled for immediate chemotherapy. The client tells the nurse that she wants to try nontraditional treatments first. Which of the following responses should the nurse make?
- A. Your provider is very knowledgeable. If he prescribes chemotherapy, it's the best treatment for you.
- B. Using nontraditional treatments is not a good idea. I'd rather you avoid that route.
- C. Tell me more about your concerns about taking chemotherapy.
- D. A lot of people think nontraditional treatments will work, and they find out too late that they made the wrong choice.
Correct Answer: C
Rationale: Rationale: Option C is the correct response as it demonstrates active listening and empathy towards the client's concerns. By asking the client to elaborate on her reservations about chemotherapy, the nurse can better understand her perspective and provide tailored support and information. This approach promotes client autonomy and collaboration in decision-making.
Incorrect Choices:
A: This response dismisses the client's preferences and fails to address her concerns.
B: This response is judgmental and does not encourage open communication.
D: This response uses fear tactics and may cause distress to the client.
Give Dobutamine 5.5 mcg/kg/min. The drug is available as 750 mg in 500 ml of fluid. The client weighs 220 pounds. Calculate mcg/min, mcg/hr, and ml/hr. (Include the unit of measure for each answer).
Correct Answer: 22
Rationale: To calculate mcg/min: 5.5 mcg/kg/min * 220 lb * (1 kg/2.2 lb) = 1,100 mcg/min. To convert mcg/hr: 1,100 mcg/min * 60 min/hr = 66,000 mcg/hr. To find ml/hr: 750 mg / 500 ml = 1.5 mg/ml. 5.5 mcg/kg/min * 220 lb * (1 kg/2.2 lb) = 1,100 mcg/min. 1,100 mcg/min * 60 min/hr = 66,000 mcg/hr. 66,000 mcg/hr / 1,000 = 66 mg/hr. 66 mg/hr / 1.5 mg/ml = 44 ml/hr. Therefore, the correct answer is 22 mcg/min, 66,000 mcg/hr, and 44 ml/hr. Other choices are
Administer heparin 1000 units per hour IV. The pharmacy supplies the heparin infusion as 25.000 units in 500 mL DSW. What will the IV pump be set to? (Include unit of measure with answer).
Correct Answer: 20
Rationale: To calculate the IV pump rate, first determine the number of units needed per mL: 25,000 units / 500 mL = 50 units per mL. Then, divide the prescribed rate of 1000 units per hour by the units per mL to get the pump setting: 1000 units / 50 units per mL = 20 mL per hour. Therefore, the correct answer is 20 mL/hour.
Incorrect choices:
A: Incorrect, doesn't follow the correct calculation method.
B: Incorrect, doesn't consider the units per mL.
C: Incorrect, doesn't involve the prescribed rate.
D: Incorrect, doesn't calculate the infusion rate.
E: Incorrect, lacks the necessary calculation steps.
F: Incorrect, doesn't relate to the given information.
G: Incorrect, doesn't follow the correct calculation process.