Nokea
An adolescent is to be admitted to the orthopedic floor with several fractures. The client has been taking hallucinogens this evening. What should the nurse expect on admission because the client is using hallucinogens?
- A. Severe depression
- B. Violent behavior
- C. Respiratory distress
- D. Convulsions
Correct Answer: B
Rationale: Hallucinogens can cause agitation or violent behavior due to altered perceptions, especially in a stressful hospital setting. Depression, respiratory distress, or convulsions are less common.
You may also like to solve these questions
The nurse is caring for a newborn with tracheoesophageal fistula. Which nursing diagnosis is a priority?
- A. Risk for dehydration
- B. Ineffective airway clearance
- C. Altered nutrition
- D. Risk for injury
Correct Answer: B
Rationale: The most common form of TEF is one in which the proximal esophageal segment terminates in a blind pouch and the distal segment is connected to the trachea or primary bronchus by a short fistula. Thus, a priority is maintaining an open airway, preventing aspiration.
A wet-to-dry dressing is ordered for a client who has a decubitus ulcer. Which technique is appropriate?
- A. Irrigate the wound and then apply a dry dressing and cover with a wet compress.
- B. Apply a wet dressing for two hours followed by a dry dressing for two hours.
- C. Apply a wet dressing, and cover with a dry dressing.
- D. Apply a wet dressing above the wound and a dry dressing below the wound.
Correct Answer: C
Rationale: Wet-to-dry dressings involve a moist gauze applied to the wound, covered with dry gauze, to debride tissue as it dries. Other techniques are incorrect.
A 19-year-old woman after delivery of a 7 lb 10 oz baby boy. The patient has decided to bottle-feed her infant.
The nurse should encourage the patient to
- A. use the manual breast pump to relieve breast engorgement.
- B. apply warm packs to the breast to relieve discomfort.
- C. massage the breasts to reduce engorgement and discomfort.
- D. wear a well supportive bra and take Tylenol for discomfort.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will encourage milk secretion (2) will enhance flow of milk (3) may be taut due to engorgement, massage would be painful and unnecessary, will encourage milk flow (4) correct-will help minimize discomfort during period of engorgement
The nurse is caring for a client with a history of cirrhosis who is receiving lactulose (Chronulac) 30 mL PO tid. Which of the following findings should the nurse report immediately?
- A. Ammonia level of 40 mcg/dL.
- B. Potassium 3.5 mEq/L.
- C. Diarrhea with 4 stools per day.
- D. Sodium 140 mEq/L.
Correct Answer: C
Rationale: Diarrhea with 4 stools per day suggests lactulose overdose, risking dehydration. Options A, B, and D are normal.
A 67-year-old man for an intravenous pyelogram (IVP).
The nurse prepares a 67-year-old man for an intravenous pyelogram (IVP). Which of the following information is MOST important for the nurse to obtain before the procedure?
- A. The date of the client's last EKG.
- B. The time of the client's last meal.
- C. A list of the client's allergies.
- D. A list of the medications the client takes at home.
Correct Answer: C
Rationale: Strategy: All answers are assessments. Determine why you would make the assessment and how it relates to the situation. (1) electrical activity of heart, not most important (2) should be NPO for 6-8 h, not most important (3) correct-involves injection of radiopaque dye, used to identify lesions and assess function, allergy to iodine is life-threatening (4) not most important