Nokea
A patient with borderline personality disorder is exhibiting self-harming behaviors. Which of the following interventions is most appropriate?
- A. Ignore the self-harming behaviors
- B. Provide immediate medical care for injuries
- C. Punish the patient for self-harming
- D. Encourage the patient to discuss their feelings
Correct Answer: B
Rationale: Providing immediate medical care for injuries ensures safety and addresses physical harm, the priority in self-harming behaviors. Ignoring, punishing, or only discussing feelings delays critical intervention.
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As a general guide for emergency management of acute alcohol intoxication, it is important for the nurse initially to obtain data regarding which of the following?
- A. What and how much the client drinks, according to family and friends
- B. The blood alcohol level of the client
- C. The blood pressure level of the client
- D. The blood glucose level of the client
Correct Answer: B
Rationale: Blood alcohol levels are generally obtained to determine the level of intoxication. The amount of alcohol consumed determines how much medication the client needs for detoxification and treatment. Reports of alcohol consumption are notoriously inaccurate.
An adult had an open cholecystectomy and has an open wound. The client refuses to look at the area during the dressing change. What is the most likely reason for this behavior?
- A. Denial of surgery
- B. Change in body image
- C. The client fears becoming nauseated at the sight of the wound.
- D. The client does not like the sight of blood.
Correct Answer: B
Rationale: Refusing to look at the wound suggests difficulty accepting a change in body image post-cholecystectomy, a common emotional response.
The nurse doing a newborn assessment counts the infant's cord vessel.
In a normal infant there are:
- A. Two vessels: one vein and one artery.
- B. Three vessels: two veins and one artery.
- C. Three vessels: one vein and two arteries.
- D. Four vessels: two veins and two arteries.
Correct Answer: C
Rationale: There are three vessels: one vein (carries oxygenated blood to the fetus) and two arteries (return deoxygenated blood to the placenta) in a normal umbilical cord.
The wife of a man who is comatose following a head injury asks the nurse if she should visit him since he is unresponsive. How should the nurse reply initially?
- A. Explain that since he is unresponsive there is no need for her to be here
- B. Tell her that the nurse will call if there is any change
- C. Suggest that her presence is important even though he seems unaware
- D. Recommend that she ask his coworkers to visit
Correct Answer: C
Rationale: Presence of loved ones may provide comfort and stimulate awareness in comatose patients, supporting family involvement. Other responses discourage visitation.
A client is admitted with low T3 and T4 levels and an elevated thyroid stimulating hormone (TSH) level. On initial assessment, the nurse would anticipate which of the following findings?
- A. Lethargy
- B. Heat intolerance
- C. Diarrhea
- D. Skin eruptions
Correct Answer: A
Rationale: Lethargy. Hypothyroidism slows metabolism, leading to symptoms like lethargy, constipation, and cold intolerance.