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A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder?
- A. I keep having recurring nightmares.
- B. I have a headache and my vision is blurry.
- C. I feel like I'm watching myself from outside my body.
- D. I hear voices telling me what to do.
Correct Answer: C
Rationale: Dissociative disorders involve a disruption in the normal integration of consciousness, memory, identity, or perception. The statement 'I feel like I'm watching myself from outside my body' is indicative of depersonalization, a common symptom of dissociative disorders. Option A is associated with PTSD, B suggests a physical issue, and D is characteristic of psychotic disorders.
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The nurse is reviewing the results of a sweat test taken from a child with cystic fibrosis. Which finding supports the client's diagnosis?
- A. A sweat potassium concentration less than 40 mEq/L
- B. A sweat chloride concentration greater than 60 mEq/L
- C. A sweat potassium concentration greater than 40 mEq/L
- D. A sweat chloride concentration less than 40 mEq/L
Correct Answer: B
Rationale: A sweat chloride concentration greater than 60 mEq/L is diagnostic for cystic fibrosis, indicating defective chloride transport.
A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?
- A. A client with AIDS being treated with Foscarnet
- B. A client with a fractured femur in a long leg cast
- C. A client with laryngeal cancer with a laryngectomy
- D. A client with diabetic ulcers to the left foot
Correct Answer: A
Rationale: Foscarnet requires monitoring for toxicity, making this client a priority.
A pregnant woman has experienced repeated vaginal monilial infections. When educating the client about the infection, which information should the nurse include? Select all that apply.
- A. Advise client to bathe daily.
- B. Explain the effects of increased estrogen production.
- C. Advise client to wear cotton panties and avoid nylon or pantyhose.
- D. Suggest client use panty liners to protect clothing.
- E. Advise the client to avoid wearing any panties.
Correct Answer: A,B,C
Rationale: Daily bathing (A), understanding estrogen's role in yeast growth (B), and wearing cotton panties (C) help manage monilial infections. Panty liners (D) may trap moisture, and avoiding panties (E) is impractical.
A client in cardiac arrest shows to be in torsades de pointes, and magnesium sulfate is ordered STAT. The priority nursing intervention is
- A. monitor client for bradycardia and respiratory depression.
- B. prepare client for synchronized cardioversion.
- C. monitor client for tachycardia and hyperventilation.
- D. prepare client for Swan catheter.
Correct Answer: A
Rationale: Magnesium sulfate for torsades de pointes can cause bradycardia and respiratory depression, requiring close monitoring.
Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence?
- A. Steadily increasing vital signs.
- B. Mild tremors and irritability.
- C. Decreased respirations and disorientation.
- D. Stomach distress and inability to sleep.
Correct Answer: A
Rationale: indication that the client is approaching delirium tremens, which can be avoided with additional sedation