Nokea
A client describing seeing snakes on the walls of his room in a psychiatric facility.
Based on this information, the nurse should identify a nursing diagnosis of
- A. sensory-perceptual alterations: visual.
- B. altered thought processes.
- C. ineffective individual coping.
- D. impaired social interaction.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-reflects a pattern of impaired perception, which is supported by the data that client is having a hallucination, defined as a sensory perception for which no external stimuli exist (2) not relevant to the data (3) not relevant to the data (4) not relevant to the data
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A 28-year-old woman at 39-weeks gestation in active labor screams, 'I have to push, I have to push.' The nurse notes that the client is 8 cm dilated.
The nurse should
- A. instruct the client to take a deep breath and bear down.
- B. apply gentle but firm fundal pressure to the client's abdomen.
- C. coach the client in relaxation techniques.
- D. tell the client to pant with pursed lips.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) pushing should be discouraged until the second stage of labor (2) would increase discomfort (3) is inappropriate at this time; this is a short, intense period of labor (4) correct-describes transition phase of labor, breathing technique allows patient to control pain and urge to push and promotes adequate oxygenation of fetus
When teaching a client with chronic obstructive pulmonary disease about oxygen by cannula, the nurse should also instruct the client's family to
- A. Avoid smoking near the client
- B. Turn off oxygen during meals
- C. Adjust the liter flow to 10 as needed
- D. Remind the client to keep mouth closed
Correct Answer: A
Rationale: Avoid smoking near the client. Oxygen supports combustion, posing a fire risk if smoking occurs nearby.
A 10-year-old for a cardiac catheterization.
Which of the following plans would be MOST appropriate for the nurse to use to prepare a 10-year-old for a cardiac catheterization?
- A. Show a videotape specifically prepared for children about cardiac catheterization.
- B. Provide the child with a pamphlet about the procedure and encourage him to read it.
- C. Draw a picture of a heart and explain where the tube will go and what the doctor will see.
- D. Present a puppet show explaining the anatomy and physiology of the heart.
Correct Answer: C
Rationale: Strategy: Think about the developmental stage of a 10-year-old. (1) video will provide correct information but is not best preparation for a school-age child (2) pamphlet will contain correct information but is not best preparation for a school-age child (3) correct-this plan will best prepare the child for the procedure (4) would be more appropriate for a younger child
An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first?
- A. Lung sounds
- B. Urine output
- C. Level of alertness
- D. Appetite
Correct Answer: C
Rationale: Level of alertness. Assessing the level of consciousness (alert vs. lethargic vs. unresponsive) will help the provider determine the severity of the acute episode. If the client is alert, responses to questions about complaints can be followed-up quickly.
A nurse assigned to a manipulative client for 5 days becomes aware of feelings of reluctance to interact with the client. The next action by the nurse should be to
- A. Discuss the feeling of reluctance with an objective peer or supervisor
- B. Limit contacts with the client to avoid reinforcement of the manipulative behavior
- C. Confront the client about the negative effects of behaviors on other clients and staff
- D. Develop a behavior modification plan that will promote more functional behavior
Correct Answer: A
Rationale: The nurse who experiences stress in the therapeutic relationship can gain objectivity through supervision. The nurse must attempt to discover attitudes and feelings in the self that influence the nurse-client relationship.