Nokea
A partner is concerned because the client frequently daydreams about moving to Arizona to get away from the pollution and crowding in southern California. The nurse explains that
- A. such fantasies can gratify unconscious wishes or prepare for anticipated future events
- B. detaching or dissociating in this way postpones painful feelings
- C. converting or transferring a mental conflict to a physical symptom can lead to conflict within the partnership
- D. isolating the feelings in this way reduces conflict within the client and with others
Correct Answer: A
Rationale: such fantasies can gratify unconscious wishes or prepare for anticipated future events. Fantasy is imagined events (daydreaming) to express unconscious conflicts or gratify unconscious wishes.
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Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority?
- A. obtain a complete blood count
- B. obtain a health and dietary history
- C. refer to a provider for a physical examination
- D. measure height and weight
Correct Answer: B
Rationale: obtain a health and dietary history. Initially, the nurse should obtain information about the chronicity of and details about constipation, recent changes in bowel habits, physical and emotional health, medications, activity pattern, and food and fluid history. This information may suggest causes as well as an appropriate, safe treatment plan.
An antibiotic IM injection for a 2 year-old child is ordered. The total volume of the injection equals 2.0 ml. The correct action is to
- A. administer the medication in 2 separate injections
- B. give the medication in the dorsal gluteal site
- C. call to get a smaller volume ordered
- D. check with pharmacy for a liquid form of the medication
Correct Answer: A
Rationale: administer the medication in 2 separate injections. Intramuscular injections should not exceed a volume of 1 ml for small children. Medication doses exceeding this volume should be split into 2 separate injections of 1.0 ml each. In adults the maximum intramuscular injection volume is 5 ml per site.
The HCP prescribes metronidazole 0.5 g orally three times daily for the client with an infection. The label states that each tablet is 250 mg. How many tablets should the nurse prepare to administer for one dose?
Correct Answer: 2
Rationale: 0.5 g = 500 mg; 500 mg/ 250 mg/tablet = 2 tablets per dose.
The charge nurse is planning hospital bed placements for the five male clients identified in the exhibit. Two double rooms and one private room are available. Which room assignments should be made by the charge nurse?
- A. Client B: private room; clients C and E in same room; clients A and D in same room
- B. Client C: private room; clients A and D in same room; clients B and E in same room
- C. Client E: private room; clients B and C in same room; clients A and D in same room
- D. Client C: private room; clients A and B in same room; clients D and E in same room
Correct Answer: B
Rationale: B: Client C requires airborne precautions and a private room. A and D share the same organism and contact precautions. B and E require standard precautions and can share a room.
A client has a chest tube inserted following a left lower lobectomy required by a stab wound to the chest. While repositioning the client, the nurse notices dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?
- A. Clamp the chest tube
- B. Call the surgeon immediately
- C. Prepare for blood transfusion
- D. Continue to monitor the rate of drainage
Correct Answer: D
Rationale: It is not unusual for blood to collect in the chest and be released into the chest drain when the client changes position. The dark color of the blood indicates it is not fresh bleeding inside the chest.