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A young adult patient constantly seeks attention from the nurses, stomping away from the nurses’ station and pouting when her requests are refused. Which of the following responses by the nurse is MOST appropriate?
- A. Have the patient establish trust with one staff person with whom therapeutic interventions should occur.
- B. Give the patient unsolicited attention when she is not exhibiting the unacceptable behaviors.
- C. Ignore the patient when she exhibits attention-seeking behavior.
- D. Rotate the staff so the patient will learn to relate to more than one nurse.
Correct Answer: B
Rationale: reward nonseeking attention behaviors by giving the patient unsolicited attention
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The nurse is caring for a client receiving IV heparin therapy for a pulmonary embolism. Which lab values would the nurse expect to order on this client?
- A. hematocrit
- B. HDL and LDL
- C. PT, PTT, INR
- D. troponin level
Correct Answer: C
Rationale: PT, PTT, and INR are monitored to assess the therapeutic effect and safety of heparin, which affects blood clotting.
The client has a prescription for a calcium carbonate compound to neutralize stomach acid. The nurse should assess the client for:
- A. Constipation
- B. Hyperphosphatemia
- C. Hypomagnesemia
- D. Diarrhea
Correct Answer: A
Rationale: Calcium carbonate can cause constipation, a common side effect, due to its effect on gastrointestinal motility.
A client tells the nurse that she is allergic to eggs, dogs, rabbits, and chicken feathers. Which order should the nurse question?
- A. TB skin test
- B. Rubella vaccine
- C. ELISA test
- D. Chest x-ray
Correct Answer: B
Rationale: The rubella vaccine is contraindicated in clients with egg allergies, as it may be grown in egg-based cultures.
The nurse is completing the preoperative checklist on a client scheduled for surgery and finds that the consent form has been signed, but the client is unclear about the surgery and possible complications. Which is the most appropriate action?
- A. Call the surgeon and ask him to come see the client to clarify the information
- B. Explain the procedure and complications to the client
- C. Check in the physician's progress notes to see if understanding has been documented
- D. Check with the client's family to see if they understand the procedure fully
Correct Answer: A
Rationale: Informed consent requires that the client understands the procedure and its risks. If the client is unclear, the surgeon, as the primary provider, should clarify the information to ensure the client's understanding, as this is a legal and ethical requirement.
A client with Addison's disease has been receiving glucocorticoid therapy. Which finding indicates a need for dosage adjustment?
- A. Dryness of the skin and mucus membranes
- B. Dizziness when rising to a standing position
- C. A weight gain of 6 pounds in the past week
- D. Difficulty in remaining asleep
Correct Answer: C
Rationale: A weight gain of 6 pounds in a week suggests fluid retention, indicating possible overdosage of glucocorticoids, requiring adjustment.