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A nurse is discussing stress management techniques with a group of clients. Which of the following techniques mentioned by a client should the nurse recognize as the least effective?
- A. I exercise when my neck is tense.
- B. I fix myself a pot of coffee when I get anxious.
- C. I pray when I begin to breathe fast.
- D. I journal when I find it difficult to talk.
Correct Answer: B
Rationale: The correct answer is B. Fixing oneself a pot of coffee when feeling anxious is the least effective stress management technique mentioned. Caffeine in coffee can exacerbate anxiety symptoms due to its stimulant properties, leading to increased heart rate and jitteriness. Exercise (A) helps release tension, prayer (C) promotes relaxation, and journaling (D) aids in expressing emotions. Choosing coffee over these more beneficial techniques can be counterproductive in managing stress.
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A nurse is teaching the parent of an adolescent who was recently diagnosed with oppositional defiant disorder (ODD). The parent asks,Is there a medication that can help my child? Which of the following responses should the nurse make?
- A. Medication is usually not prescribed to treat oppositional defiant disorder. Let's discuss some behavioral strategies you can use.
- B. There are many medications that will help your child manage aggression and destructiveness. The health care provider will discuss them with you.
- C. Medication is not used to treat this oppositional defiant disorder because it is behavioral in nature.
- D. It's a common misconception that there is a medication available to treat every health problem.
Correct Answer: A
Rationale: The correct answer is A: Medication is usually not prescribed to treat oppositional defiant disorder. Let's discuss some behavioral strategies you can use. ODD is primarily a behavioral disorder, not a chemical imbalance, so medication is not typically the first-line treatment. Behavioral strategies such as cognitive-behavioral therapy, parent training, and family therapy are more effective in managing ODD symptoms. Other choices are incorrect because they either suggest medication as the primary treatment without acknowledging the behavioral aspect of ODD (B), state inaccuracies about medication use for ODD (C), or divert the conversation away from addressing the parent's concerns (D).
A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as possible risk factors for iron deficiency anemia?
- A. The client eats red meat daily.
- B. The client has had gastric bypass surgery.
- C. The client has had treatment for gastrointestinal cancer.
- D. The client eats mostly prepackaged,processed foods.
- E. The client has ulcerative colitis.
Correct Answer: B,C,D,E
Rationale: The correct answer includes choices B, C, D, and E. Gastric bypass surgery can lead to malabsorption of iron, increasing the risk of anemia. Treatment for gastrointestinal cancer can also affect iron absorption. Eating mostly prepackaged, processed foods may lack iron-rich foods, contributing to anemia risk. Ulcerative colitis can cause intestinal bleeding, leading to iron deficiency. Choice A is incorrect as red meat is a good source of iron.
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.
A nurse is assessing a client diagnosed with schizophrenia who has been treated with fluphenazine (Prolixin) for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?
- A. Sudden onset of high fever
- B. Twisting tongue movements
- C. Constant tapping of feet when sitting
- D. Shuffling gait
Correct Answer: B
Rationale: Twisting tongue movements are a classic sign of tardive dyskinesia from long-term antipsychotic use.
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.