Nokea
A primary belief of psychiatric mental health nursing is:
- A. most people have the potential to change and grow.
- B. every person is worthy of dignity and respect.
- C. human needs are individual to each person.
- D. some behaviors have no meaning and cannot be understood.
Correct Answer: B
Rationale: The belief that every person is worthy of dignity and respect is foundational to psychiatric mental health nursing, emphasizing client-centered care. The other options are also relevant but not the primary belief highlighted here. Psychosocial Integrity
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The nurse is administering terbutaline (Brethine) to a client in labor. Prior to administration of the medication, the nurse assesses the client's pulse to be 144. The nurse's priority action should be to
- A. withhold the medication.
- B. decrease the dose by half.
- C. administer the medication.
- D. wait 15 minutes, then recheck the rate.
Correct Answer: A
Rationale: Terbutaline, a tocolytic, can cause maternal tachycardia. A pulse of 144 indicates significant tachycardia, a side effect requiring the medication to be withheld to prevent further cardiovascular strain. Decreasing the dose (B) is not within nursing scope, administering (C) ignores the risk, and waiting (D) delays intervention.
A male patient with thrombophlebitis is apprehensive about the possibility of a clot reaching his heart, causing sudden death.
The nurse's initial intervention should be to:
- A. Clarify his misconception.
- B. Explain preventive measures.
- C. Teach recognition of early symptoms.
- D. Encourage discussion of the patient's concern.
Correct Answer: A
Rationale: Clarifying that thrombophlebitis clots rarely reach the heart addresses the patient's fear directly.
A nurse is administering blood to a patient who has a low hemoglobin count.
The patient asks how long the RBC last in the body? The correct response is:
- A. The life span of RBC is 45 days.
- B. The life span of RBC is 60 days.
- C. The life span of RBC is 90 days.
- D. The life span of RBC is 120 days.
Correct Answer: D
Rationale: Red blood cells have a lifespan of approximately 120 days.
B.C underwent skin grafting. Vital signs are BP 124/68; HR 100 bpm; RR 24; T 37.7 °C.
Potential complication that can be possibly developed will be:
- A. Sepsis
- B. Hypovolemic
- C. Pain
- D. Electrolyte imbalance
Correct Answer: A
Rationale: Infection, such as sepsis, is a serious complication of skin grafting due to the risk of microbial invasion at the graft site.
Dual diagnosis indicates that there is a substance abuse problem as well as a
- A. cross addiction
- B. mental disorder
- C. disorder of any type
- D. medical problem
Correct Answer: B
Rationale: Dual diagnosis is the concurrent presence of a major psychiatric disorder and chemical dependence.