Nokea
A patient who completed detoxing from heroin tells you that his or her family members who are not substance abusers do not understand how it feels to go through withdrawal. He or she asks you for advice. Which of the following is the best response?
- A. Tell your family members to attend Alcoholics Anonymous.
- B. Ask your family members if they ever had the flu. Tell them that withdrawal is like having the worst flu they ever had.
- C. Tell your family member that going through withdrawal is like going on a diet.
- D. Tell your family member to try heroin once.
Correct Answer: B
Rationale: Comparing withdrawal to a severe flu helps family members understand the physical symptoms without trivializing the experience.
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What is the priority intervention for a patient admitted to your unit diagnosed with advanced amyotrophic lateral sclerosis (ALS)?
- A. Develop a method of communication.
- B. Provide six small meals high in protein and assist with feeding.
- C. Do not involve the patient in decisions about his healthcare because he is not in the mental state to respond.
- D. Provide six normal meals high in protein and assist with feeding.
Correct Answer: A
Rationale: Communication becomes critical as ALS progresses and affects motor functions.
Why is it important for a nurse to move a victim of a common respiratory toxin to higher ground immediately?
- A. The toxins flow to the lower ground.
- B. The toxic vapors stay close to the ground.
- C. The toxins are always released close to the ground.
- D. The heavy and the solid toxins cannot move to a height.
Correct Answer: B
Rationale: The correct answer is B because many respiratory toxins are heavier than air and settle near the ground.
What volume of fluid loss causes marked deterioration in hypovolemic shock?
- A. 30% to 40% (1500 mL to 2000 mL)
- B. 15% to 30% (750 mL to 1500 mL)
- C. 10% to 15% (500 mL to 750 mL)
- D. More than 40% (more than 2000 mL)
Correct Answer: B
Rationale: Loss of 15% to 30% of blood volume significantly impairs circulation and tissue perfusion.
How would you respond to a family member experiencing anticipatory grieving who emotionally withdraws from the client?
- A. Encourage continued engagement and communication.
- B. Allow space while offering support and reassurance.
- C. Advise them to focus solely on practical matters.
- D. Recommend avoiding the client until after their passing.
Correct Answer: B
Rationale: Offering support while respecting emotional withdrawal helps family members process grief at their own pace.
While providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?
- A. It decreases the client's level of anxiety.
- B. It facilitates the client's deep breathing.
- C. It enhances the client's ability to sleep.
- D. It reduces the client's blood pressure.
Correct Answer: B
Rationale: The correct answer is B because facilitating the client's deep breathing is crucial post-CABG surgery to prevent complications such as atelectasis and pneumonia. Deep breathing helps improve lung expansion and oxygenation, promoting healing and preventing respiratory issues.
A: While decreasing anxiety is important for overall well-being, it is not directly related to the client's recovery post-CABG surgery.
C: Enhancing sleep is beneficial for healing, but it is not as critical as ensuring proper respiratory function in the immediate postoperative period.
D: While reducing blood pressure may be desirable in some cases, it is not the most important effect to focus on post-CABG surgery; maintaining adequate oxygenation through deep breathing takes precedence.