Nokea
A nurse is caring for a patient with major depressive disorder. Which of the following interventions is most appropriate?
- A. Encourage the patient to spend time alone
- B. Discourage the patient from expressing feelings
- C. Encourage participation in group activities
- D. Avoid discussing the patient's feelings
Correct Answer: C
Rationale: Group activities promote socialization and reduce isolation in depression, supporting recovery. Encouraging alone time or avoiding feelings worsens symptoms, and expression should be encouraged therapeutically.
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The nurse observes a LPN/LVN perform a wet-to-dry dressing change on a 2-inch abdominal incision. Which of the following behaviors, if performed by the LPN/LVN, would indicate an understanding of proper technique?
- A. A clean cotton ball is used to cleanse from the top of the incision to the bottom of the incision using long strokes.
- B. The incision is packed with sterile gauze, and then sterile saline is poured over the dressing.
- C. The nurse packs wet gauze into the incision without overlapping it onto the skin.
- D. The old dressing is saturated with sterile saline before it is removed.
Correct Answer: C
Rationale: Wet-to-dry dressings should have wet gauze packed into the incision without overlapping onto the skin to prevent skin breakdown. Cleansing (A) should be from the center outward, dressings (B) are soaked before packing, and old dressings (D) are removed dry to debride the wound.
The nurse is providing discharge teaching for a client with a history of alcoholism. Which of the following statements, if made by the client, indicates that the client understands the teaching?
- A. I should avoid all products that contain alcohol, including cough medicines.'
- B. I can have one drink a week as long as I dilute it with water.'
- C. I should continue to drink nonalcoholic beer to satisfy my taste for beer.'
- D. I can stop taking disulfiram (Antabuse) once I feel better.'
Correct Answer: A
Rationale: Complete abstinence is required for alcoholism recovery, including avoiding alcohol-containing products like cough medicines, which could trigger relapse. Diluted drinks (B) or nonalcoholic beer (C) risk relapse due to taste cues, and stopping disulfiram prematurely (D) increases relapse risk.
The client's blood gas values are: pH=7.35; CO2=60; HCO3=34; and pO2=60. The nurse correctly interprets these to indicate that the client is in which state?
- A. Compensated respiratory acidosis
- B. Partly compensated metabolic alkalosis
- C. Metabolic alkalosis
- D. Metabolic acidosis
Correct Answer: A
Rationale: Normal pH with elevated CO2 and HCO3 indicates compensated respiratory acidosis, where kidneys retain bicarbonate to balance chronic CO2 retention.
Thrombus formation is a danger for all post operative patients. The nurse should act independently to prevent this complication by:
The nurse should act independently to prevent this complication by:
- A. Applying elastic stockings.
- B. Massaging gently with lotion.
- C. Encouraging in-bed exercises.
- D. Providing adequate fluids intake.
Correct Answer: C
Rationale: In-bed exercises promote venous return, reducing the risk of thrombus formation.
The mother's condition has deteriorated during labor and a cesarean section is required. Her husband is worried and anxious about the changed of plan and demand for an explanation.
Who among the following should explain the procedure to the husband?
- A. The surgeon.
- B. The attending physician.
- C. The primary nurse.
- D. The medical team.
Correct Answer: A
Rationale: The surgeon, as the procedure performer, is best suited to explain the cesarean section.