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A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include in the plan?
- A. Hyperextend the client's neck.
- B. Instruct the client to deep breathe every 4 hr.
- C. Place the head of the client's bed in the flat position.
- D. Check the client's voice every 2 hr.
Correct Answer: B,D
Rationale: The correct answers are B and D. Instructing the client to deep breathe every 4 hours helps prevent respiratory complications post-thyroidectomy. Checking the client's voice every 2 hours is important to monitor for vocal cord damage, a potential complication. Choice A is incorrect as hyperextending the client's neck can put strain on the surgical site. Choice C is incorrect as the head of the bed should be elevated to reduce swelling and promote drainage.
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A nurse in a substance abuse clinic is assessing a client who is prescribed disulfiram (Antabuse). The client states he stopped the medication after developing severe nausea and vomiting. Which of the following does the nurse realize is most likely the cause of the client's symptoms?
- A. The client took an overdose of the medication.
- B. The client demonstrated an allergic response to the medication.
- C. The client experienced a common side effect of the medication.
- D. The client consumed alcohol while taking the medication.
Correct Answer: D
Rationale: The correct answer is D: The client consumed alcohol while taking the medication. Disulfiram is used to deter alcohol consumption by causing unpleasant reactions when alcohol is ingested. The symptoms of severe nausea and vomiting the client experienced are consistent with the disulfiram-alcohol reaction. This reaction occurs when alcohol is consumed while on disulfiram, leading to a buildup of acetaldehyde, causing discomfort.
Choice A: The client taking an overdose of the medication would typically result in different symptoms, such as neurological effects or liver toxicity.
Choice B: An allergic response to disulfiram would likely manifest as skin rash, itching, or difficulty breathing, rather than nausea and vomiting.
Choice C: While nausea and vomiting are common side effects of disulfiram, they are typically milder and occur when alcohol is consumed, not as a standalone symptom.
Give Dobutamine 5.5 mcg/kg/min. The drug is available as 750 mg in 500 ml of fluid. The client weighs 220 pounds. Calculate mcg/min, mcg/hr, and ml/hr. (Include the unit of measure for each answer).
Correct Answer: 22
Rationale: To calculate mcg/min: 5.5 mcg/kg/min * 220 lb * (1 kg/2.2 lb) = 1,100 mcg/min. To convert mcg/hr: 1,100 mcg/min * 60 min/hr = 66,000 mcg/hr. To find ml/hr: 750 mg / 500 ml = 1.5 mg/ml. 5.5 mcg/kg/min * 220 lb * (1 kg/2.2 lb) = 1,100 mcg/min. 1,100 mcg/min * 60 min/hr = 66,000 mcg/hr. 66,000 mcg/hr / 1,000 = 66 mg/hr. 66 mg/hr / 1.5 mg/ml = 44 ml/hr. Therefore, the correct answer is 22 mcg/min, 66,000 mcg/hr, and 44 ml/hr. Other choices are
A nurse is reviewing the history and physical of an adolescent client diagnosed with conduct disorder. The nurse recognizes that which of the following is an expected assessment finding of conduct disorder?
- A. Death of client's father two months ago
- B. Experiences frequent facial tics
- C. Adheres strictly to routines
- D. Suspended from school several times in the past year
Correct Answer: D
Rationale: The correct answer is D: Suspended from school several times in the past year. Conduct disorder is characterized by persistent patterns of behavior that violate the rights of others and societal norms. Being suspended from school multiple times indicates a disregard for rules and authority, which is a common feature of conduct disorder. Choices A, B, and C do not directly align with the typical behaviors associated with conduct disorder. A recent death in the family (A) may lead to emotional distress but is not a defining characteristic of conduct disorder. Frequent facial tics (B) are more indicative of a neurological or psychological condition, not conduct disorder. Adhering strictly to routines (C) is more characteristic of obsessive-compulsive disorder, not conduct disorder.
A male client is admitted to the unit with a possible diagnosis of delirium. Which statement by the client's wife best supports the diagnosis?
- A. Since his mother died, he has not been feeling well.
- B. My husband just didn't seem to know what he was doing. He has been forgetful for years.
- C. The changes in his behavior came on so quickly! I wasn't sure what was happening.
- D. This is supposed to happen when you get old, right?
Correct Answer: C
Rationale: The correct answer is C because delirium is characterized by a rapid onset of confusion, changes in behavior, and altered mental status. The wife's statement about the changes in behavior coming on quickly aligns with this key characteristic of delirium.
Choice A is incorrect because the client's feelings after his mother's death are not necessarily related to delirium. Choice B is incorrect because long-term forgetfulness is more indicative of dementia rather than delirium. Choice D is incorrect because delirium is not a normal part of aging.
Claudette, the nurse, is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication
- A. I feel angry when you leave me.
- B. I wish you would not make me angry.
- C. It makes me angry when you interrupt me.
- D. You'd better listen to me.
Correct Answer: D
Rationale: The correct answer is D because it is an example of aggressive communication. The statement "You'd better listen to me" is forceful, directive, and implies a threat if the listener does not comply. This type of communication lacks respect for the other person's feelings and boundaries. In contrast, choices A, B, and C express personal feelings and thoughts without being demanding or confrontational. Choice A uses "I feel" to express emotions, choice B expresses a wish without placing blame, and choice C explains a reaction to a specific behavior without being forceful. Therefore, D stands out as the only example of aggressive communication in the given options.