Nokea
A nurse is interviewing an 8-year-old girl who was admitted to the pediatric unit. Which statement by the child needs to be explored?
- A. Wow! This place has bright colors.'
- B. Is my mother allowed to visit me tonight?'
- C. Those boys are so cute. I hope their room is next to mine?'
- D. I am scared about being here. Can you stay with me awhile?'
Correct Answer: D
Rationale: Expressing fear signals anxiety needing exploration, unlike curiosity (A, B) or social interest typical for this age.
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Which approaches should a nurse use during crisis intervention?
- A. Active
- B. Passive
- C. automative
- D. Interpretative
Correct Answer: A
Rationale: Active and reflective approaches guide crisis intervention effectively.
When planning care for a client who has ingested phencyclidine (PCP), the nurse is aware that the following is the highest priority?
- A. Client's physical needs
- B. Client's safety needs
- C. Client's psychosocial needs
- D. Client's medical needs
Correct Answer: B
Rationale: The highest priority for a client who has ingested PCP is meeting safety needs of the client as well as the staff. Drug effects are unpredictable and prolonged, and the client may lose control easily. After safety needs are met, the client's physical, psychosocial, and medical needs can be met.
A nurse is teaching clients about dietary restrictions when taking a monoamine oxidase inhibitor (MAOI). What response does the nurse tell them to anticipate if they do not follow these restrictions?
- A. Occipital headaches
- B. Generalized urticaria
- C. Severe muscle spasms
- D. Sudden drop in blood pressure
Correct Answer: A
Rationale: MAOI-tyramine interactions cause hypertensive crises, often with occipital headaches .
The nurse is aware that which assessment finding is most consistent with early alcohol withdrawal?
- A. Heart rate of 120-140 beats/minute
- B. Heart rate of 50-60 beats/minute
- C. Blood pressure of 100/70 mmHg
- D. Blood pressure of 140/80 mmHg
Correct Answer: A
Rationale: Tachycardia, a heart rate of 120-140 beats/minute, is a common sign of alcohol withdrawal. Blood pressure may be labile throughout withdrawal, fluctuating at different stages. Hypertension typically occurs in early withdrawal. Hypotension, although rare during the early withdrawal stages, may occur in later stages. Hypotension is associated with cardiovascular collapse and most commonly occurs in clients who don't receive treatment. The nurse should monitor the client's vital signs carefully throughout the entire alcohol withdrawal process.
In the process of development the individual strives to maintain, protect, and enhance the integrity of the self. The nurse determines that this usually is accomplished through the use of:
- A. affective reactions
- B. withdrawal patterns
- C. ritualistic behaviors
- D. defense mechanisms
Correct Answer: D
Rationale: Defense mechanisms protect the ego by managing anxiety and maintaining self-integrity, per psychoanalytic theory.