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Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley's level of anxiety as:
- A. mild.
- B. moderate.
- C. severe.
- D. panic.
Correct Answer: C
Rationale: The person whose anxiety is assessed as severe is unable to solve problems and has a poor grasp of what's happening in his or her environment. Somatic symptoms such as those described by Ashley are usually present. Vital sign changes are observed. The individual with mild anxiety might report being mildly uncomfortable and might even find performance enhanced. The individual with moderate anxiety grasps less information about the situation, has some difficulty problem-solving, and might have mild changes in vital signs. The individual in panic demonstrates markedly disturbed behavior and might lose touch with reality.
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In alcoholics with anemia:
- A. pernicious anemia is more common than folic acid deficiency.
- B. iron deficiency and folic acid deficiency can coexist.
- C. the alcohol interferes with iron absorption.
- D. oral vitamin replacement is contraindicated.
Correct Answer: B
Rationale: The ingestion of nonfood substances (alcohol) can lead to a clinical iron deficiency and might actually be the first sign of a problem. The client might substitute alcohol for a nutrition program that fosters a positive health habit.
Incidences of child abuse appear to be higher in the African-American community and might be explained by:
- A. The increased number of African Americans viewing violence on television
- B. More single-parent households in African-American communities
- C. Stricter child-rearing practices in African-American households
- D. A higher occurrence of rage in African Americans
Correct Answer: B
Rationale: Higher child abuse rates in African-American communities correlate with socioeconomic stress and single-parent households, not violence exposure, strict practices, or inherent rage.
Legal protection of confidentiality:
- A. extends only to written documentation.
- B. extends to the electronic dissemination of information not identifiable to a specific client.
- C. is important only within the court system.
- D. extends to both written and verbal information.
Correct Answer: D
Rationale: Legal protection of confidentiality extends to both written and verbal information identifiable as individual private health information.
A person using over-the-counter nasal decongestant drops who reports unrelieved and worsening nasal congestion should be instructed to:
- A. switch to a stronger dose of the medication.
- B. discontinue the medication for a few weeks.
- C. continue taking the same medication, but use it more frequently.
- D. use a combination of medications for better relief.
Correct Answer: B
Rationale: Prolonged use of decongestant drops (3 to 5 days) can lead to rebound congestion, which is relieved by discontinuing the medication for 2 to 3 weeks. Nasal congestion results from dilation of nasal blood vessels due to infection, inflammation, or allergy. With this dilation, there is a transudation of fluid into the tissue spaces, resulting in swelling of the nasal cavity. Nasal decongestants (sympathomimetic amines) stimulate the alpha-adrenergic receptors, producing vascular constriction (vasoconstriction) of the capillaries within the nasal mucosa. The result is shrinking of the nasal mucous membranes and a reduction in fluid secretion (runny nose). Decongestants can make a client jittery, nervous, or restless. These side effects decrease or disappear as the body adjusts to the drug. When nasal decongestants are used for longer than 5 days, instead of the nasal membranes constricting, vasodilation occurs, causing increased stuffy nose and nasal congestion. The nurse should emphasize the importance of limiting the use of nasal sprays and drops. As with any alpha-adrenergic drug (for example, decongestants), blood pressure and blood glucose levels can increase. These drugs are contraindicated and should only be used with extreme caution for clients with hypertension, cardiac disease, hyperthyroidism, and diabetes mellitus.
The nurse can best communicate to a client that he or she has been listening by:
- A. restating the main feeling or thought the client has expressed.
- B. making a judgment about the client's problem.
- C. offering a leading question such as, 'And then what happened?'
- D. saying, 'I understand what you're saying.'
Correct Answer: A
Rationale: Restating allows the client to validate the nurse's understanding of what has been communicated. It's an active listening technique. Judgments should be suspended in a nurse-client relationship. Leading questions ask for more information rather than showing understanding. Saying 'I understand' communicates understanding, but the client has no way of measuring the understanding.