Nokea
Alcohol and drug abuse impairs judgment and increases risk taking behavior. What nursing diagnosis best applies?
- A. Risk for injury
- B. Risk for knowledge deficit
- C. Altered thought process
- D. Disturbance in self-esteem
Correct Answer: A
Rationale: Risk for injury. Impaired judgment from substance abuse significantly increases the risk of accidents and injuries.
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An adult woman is admitted to an acute locked psychiatric unit one month prior to an election.
Which of the following responses by the nurse is BEST?
- A. You are not eligible to vote because you are a psychiatric patient.'
- B. I'll make the appropriate arrangements for you to vote.'
- C. You may vote only if you are discharged by Election Day.'
- D. I'll contact the Election Board to see if you are registered to vote.'
Correct Answer: B
Rationale: Strategy: Determine the outcome of each answer choice. (1) psychiatric patients do not forfeit their constitutional rights (2) correct-patient can vote by absentee ballot (3) can vote by absentee ballot (4) not the nurse's responsibility
The nurse is planning care for a 2 year-old hospitalized child. Which of the following will produces the most stress at this age?
- A. Separation anxiety
- B. Fear of pain
- C. Loss of control
- D. Bodily injury
Correct Answer: A
Rationale: Separation anxiety. While a toddler will experience all of the stresses, separation from parents is the major stressor.
A client had a radical mastectomy for cancer in her right breast.
After the client returns to the unit, which of the following actions, if performed by the nurse, would be MOST appropriate?
- A. Position the client on her left side with her right arm protected in a sling.
- B. Position the client on her right side with her right arm elevated.
- C. Position the client in semi-Fowler's position with her right arm elevated.
- D. Position the client in the prone position with her right arm elevated.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) sling is not necessary, arm needs to be elevated (2) right arm cannot be elevated from this position (3) correct-this position will facilitate removal of fluid from venous pathways and lymphatic system through gravity; arm is elevated to enhance circulation and prevent edema (4) prone position is not appropriate
An extremely angry patient with bipolar illness who just learned his wife has filed for divorce.
Which of the following responses by the nurse is MOST appropriate?
- A. Allow the patient to use the phone.
- B. Confront the patient about his anger and inappropriate plan of action.
- C. Do not allow the patient to use the phone because he is an involuntary patient.
- D. Set limits on the patient's phone use because he has been unable to control his behavior.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-patient is able to use phone unless otherwise indicated by court order or physician's order (2) has not lost civil right to use phone (3) denies patient his civil rights (4) inappropriate
Treatment of sickle cell crises includes the application of:
- A. A heating pad to the joints
- B. An ice pack to the joints
- C. A CPM device to the lower leg
- D. A TENS unit to the back
Correct Answer: A
Rationale: Heat application to joints during sickle cell crises promotes vasodilation, improving blood flow and reducing pain from vaso-occlusion. Ice may worsen vasoconstriction, CPM is irrelevant, and TENS is not standard for sickle cell pain.