Nokea
A nurse is caring for a group of older adult clients. Which of the following manifestations indicates one of the clients is experiencing delirium?
- A. A client attempts to climb out of bed and repeatedly states she must get home.
- B. A client refuses to get out of bed and has no motivation to attend to daily hygiene.
- C. A client wants to know the current time while there is a clock on the wall.
- D. A client requests extra blankets when the thermostat in the room indicates 25.6°C (78°F).
Correct Answer: A
Rationale: The correct answer is A. Delirium is characterized by sudden onset confusion and disorientation. In this case, the client attempting to climb out of bed and repeatedly stating she must get home indicates altered mental status and confusion, which are common in delirium. The other choices do not align with typical manifestations of delirium. Choice B suggests lack of motivation, choice C is a normal behavior to check the time, and choice D is a reasonable request based on personal preference rather than a sign of delirium.
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A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?
- A. Determining the cause of the client's anxiety
- B. Identifying the client's coping skills
- C. Protecting the client from injury to himself
- D. Ensuring that the client feels safe
Correct Answer: C
Rationale: The correct answer is C: Protecting the client from injury to himself. This is the highest priority because during a crisis intervention for acute anxiety, the client may be at risk of harming themselves. Ensuring their safety is crucial before addressing other needs. Option A is important but not the highest priority in this acute situation. Option B is relevant but not as urgent as ensuring safety. Option D is also important, but physical safety takes precedence over emotional safety.
The physician orders a Lidocaine drip to infuse at 2 mg/min. The drug is available as 2 gm in 500 mL of fluid. Solve for mL/hr.
Correct Answer: 3
Rationale: To solve for mL/hr, we first need to convert 2 gm to mg (2000 mg) and calculate the total volume in mL (500 mL). Then, we divide the total volume by the rate of infusion (2 mg/min) to get mL/min (250 mL/min). Finally, multiply this by 60 to get mL/hr (15000 mL/hr). Choice 3 is correct because it correctly follows these steps. Other choices are incorrect due to miscalculations or skipping a step.
According to Bowen's theoretical approach to therapy,which of the following should the nurse recognize as a concept of a functional family interaction pattern?
- A. Marital skew
- B. Sibling position
- C. Double-bind communication
- D. Pseudomutuality
Correct Answer: B
Rationale: According to Bowen's theoretical approach, sibling position is a concept of a functional family interaction pattern. This refers to the role and position each sibling holds within the family system, influencing their behavior and relationships. Understanding sibling positions helps assess family dynamics and interactions. Marital skew, double-bind communication, and pseudomutuality are not specific concepts of a functional family interaction pattern in Bowen's theory. Marital skew refers to imbalance in spousal relationships, double-bind communication involves conflicting messages, and pseudomutuality is a false sense of harmony.
The nurse is teaching a client about cellular hypertrophy. Which statement should be included in the teaching?
- A. It's uncontrolled proliferative cell growth that is cancerous.
- B. It's the enlargement of an organ or tissue from the increase in cell size.
- C. It's the wasting away of tissue or organs.
- D. It's the abnormal growth or development of cells.
Correct Answer: B
Rationale: The correct answer is B because cellular hypertrophy refers to the increase in the size of cells leading to the enlargement of an organ or tissue. This is a normal physiological response to increased demand or stress. Choice A is incorrect as uncontrolled proliferative cell growth leading to cancer is known as neoplasia, not hypertrophy. Choice C is incorrect as wasting away of tissue is termed as atrophy, not hypertrophy. Choice D is incorrect as abnormal cell growth or development is more indicative of dysplasia or metaplasia, not hypertrophy.
A nurse is talking with the guardian of a school-aged child recently diagnosed with intermittent explosive disorder (IED). The guardian says,My child is impulsive, acts out aggressively, and then seems pleased with themselves. How can my child be happy? Which of the following responses should the nurse make?
- A. Appearing pleased after an aggressive or impulsive act has not been directly linked to intermittent explosive disorder.
- B. Appearing pleased after an aggressive or impulsive act can be a sense of relief rather than being happy.
- C. Appearing pleased after an aggressive or impulsive act is a manifestation of lack of empathy or compassion.
- D. Appearing pleased after an aggressive or impulsive act is within the control of your child.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: The nurse should choose response B because it addresses the guardian's concern accurately. Individuals with intermittent explosive disorder may experience a sense of relief rather than genuine happiness after acting out aggressively. This relief can stem from a temporary release of pent-up emotions or stress. It is important for the nurse to clarify this distinction to the guardian to help them understand their child's behavior better and guide appropriate interventions.
Incorrect Choices:
A: This response dismisses the guardian's observations and does not provide a helpful explanation.
C: This response inaccurately suggests a lack of empathy or compassion, which is not a defining characteristic of intermittent explosive disorder.
D: This response implies that the behavior is under the child's control, which is not necessarily the case with impulsive disorders like IED.