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A nurse is assessing a client who has histrionic personality disorder. Which of the following manifestations should the nurse expect?
- A. Suspicious of others
- B. Callousness
- C. Self-centered behavior
- D. Violates other's rights
Correct Answer: C
Rationale: The correct answer is C: Self-centered behavior. Individuals with histrionic personality disorder typically exhibit attention-seeking, dramatic, and overly emotional behaviors. They often crave approval and validation from others, focusing on themselves and their own needs. This behavior aligns with the core characteristics of histrionic personality disorder.
Choice A (Suspicious of others) is incorrect as suspicion is not a defining trait of histrionic personality disorder. Choice B (Callousness) is inconsistent as histrionic individuals tend to be overly emotional rather than callous. Choice D (Violates other's rights) is not a common feature of histrionic personality disorder.
In summary, the nurse should expect self-centered behavior in a client with histrionic personality disorder, as they typically display attention-seeking and dramatic behaviors, seeking validation and approval from others.
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A nurse and an assistive personnel (AP) are assigned a group of clients on the unit. Which of the following clients should the nurse instruct the AP to report to the nurse?
- A. A client who requests assistance to use the bedside commode
- B. A client who has a prescription for compression stockings and did not receive them
- C. A client who requests to sit in the bedside chair while watching TV
- D. A client who consumes all the food from their meal tray
Correct Answer: B
Rationale: Correct Answer: B - A client who has a prescription for compression stockings and did not receive them should be reported to the nurse.
Rationale: Compression stockings are a prescribed medical intervention for a specific reason, such as preventing blood clots or managing edema. Failure to provide them can lead to serious health consequences. The nurse needs to be informed immediately to address this issue promptly.
Summary of Other Choices:
A: A client requesting assistance to use the bedside commode is within the scope of the AP's duties and does not require immediate nurse intervention.
C: A client requesting to sit in a bedside chair is a basic comfort measure and does not require immediate nurse intervention.
D: A client consuming all the food from their meal tray is not a cause for immediate concern and does not require nurse intervention at that moment.
A nurse is assessing a client who received hydromorphone 4 mg IV 15 min ago. The client has a respiratory rate of 10/min. The nurse should prepare to administer which of the following medications?
- A. Acetylcysteine
- B. Protamine
- C. Naloxone
- D. Flumazenil
Correct Answer: C
Rationale: The correct answer is C: Naloxone. Naloxone is an opioid antagonist used to reverse the effects of opioid overdose, such as respiratory depression. In this case, the client's respiratory rate of 10/min indicates opioid overdose due to hydromorphone. Naloxone administration can help reverse the respiratory depression and restore normal breathing.
Choice A: Acetylcysteine is used for acetaminophen overdose, not opioid overdose.
Choice B: Protamine is used to reverse the effects of heparin, not opioids.
Choice D: Flumazenil is a benzodiazepine antagonist, not an opioid antagonist.
Therefore, the most appropriate choice in this scenario is Naloxone to address the opioid overdose and respiratory depression.
The nurse is reviewing the assessment findings. For each assessment finding, click to specify if the finding is consistent with preeclampsia or HELLP syndrome. Each finding may support more than one disease process
- A. Hemoglobin
- B. Alanine aminotransferase (ALT)
- C. Blood pressure
- D. Platelet count
Correct Answer: C: Preeclampsia; A, B, D: HELLP
Rationale: The correct answer is: C: Preeclampsia; A, B, D: HELLP.
1. Blood pressure is consistent with preeclampsia as elevated blood pressure is a key characteristic.
2. Hemoglobin, Alanine aminotransferase (ALT), and Platelet count are consistent with HELLP syndrome, as these markers are commonly affected in this condition.
3. Preeclampsia is characterized by hypertension and proteinuria, while HELLP syndrome involves hemolysis, elevated liver enzymes, and low platelet count.
4. Therefore, based on the assessment findings provided, elevated blood pressure aligns with preeclampsia, while abnormalities in hemoglobin, ALT, and platelet count suggest HELLP syndrome.
A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Replace the carpet with hardwood floors
- B. Encourage physical activity prior to bedtime
- C. Wear clothing with zippers instead of buttons
- D. Place locks at the tops of exterior doors
Correct Answer: D
Rationale: The correct answer is D: Place locks at the tops of exterior doors. This is important because individuals with Alzheimer's disease may wander and become lost. Placing locks at the tops of exterior doors can help prevent the client from leaving the home unsupervised and potentially getting lost or injured.
A: Replacing the carpet with hardwood floors is not directly related to the safety of the client with Alzheimer's disease.
B: Encouraging physical activity prior to bedtime may actually disrupt sleep patterns for individuals with Alzheimer's disease.
C: Wearing clothing with zippers instead of buttons may not significantly impact the client's safety.
Overall, option D is the most appropriate choice to ensure the safety and well-being of the client with Alzheimer's disease.
A nurse is caring for a client who is near the end of life and is on complete bed rest. The client states that he needs to have a bowel movement, and the nurse offers a bed pan. The client states, 'I've always used the bathroom.' Which of the following responses should the nurse make?
- A. Tell me what concerns you have about using a bed pan.'
- B. Make sure to use nearby furniture to support yourself when walking to the bathroom.'
- C. I will have the physical therapist ambulate you to the bathroom.'
- D. You have to use the bed pan for your own safety.'
Correct Answer: A
Rationale: The correct answer is A: "Tell me what concerns you have about using a bed pan." This response demonstrates therapeutic communication by acknowledging the client's feelings and allowing them to express their concerns. By understanding the client's perspective, the nurse can address specific fears or preferences related to using the bed pan. This approach promotes client autonomy and dignity.
Choice B is incorrect because it disregards the client's expressed need for a bowel movement while on complete bed rest. Choice C is inappropriate as it assumes the client is physically able to be ambulated to the bathroom, which may not be the case. Choice D is incorrect as it is a directive statement that does not address the client's concerns or preferences.