Nokea
Delirium tremens could best be described as
- A. Disorganized thinking, feelings of terror and non-purposeful behavior
- B. A generalized shaking of the body accompanied by repetitive thoughts
- C. An excited state accompanied by disorientation, hallucination and tachycardia
- D. Single or multiple jerks caused by rapid contracting muscles
Correct Answer: C
Rationale: An excited state accompanied by disorientation, hallucination and tachycardia. Delirium tremens involves severe withdrawal symptoms, including confusion, hallucinations, and autonomic hyperactivity.
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A newborn is to be discharged in the AM.
The nurse should teach the child's mother to perform which of the following actions?
- A. Apply a sterile gauze dressing with petroleum jelly to the cord.
- B. Position the diaper over the umbilicus to keep it dry.
- C. Clean the cord several times a day and expose it to air frequently.
- D. Apply erythromycin ointment to the cord several times a day.
Correct Answer: C
Rationale: Strategy: The topic of the question is unstated. (1) appropriate for circumcision (2) will keep the area moist; the diaper should be placed below the umbilicus (3) correct-encourages drying and helps to prevent infection (4) antibiotic ointment is unnecessary
Based on principles of teaching and learning, what is the best initial approach to pre-op teaching for a client scheduled for coronary artery bypass?
- A. Touring the coronary intensive unit
- B. Mailing a video tape to the home
- C. Assessing the client's learning style
- D. Administering a written pre-test
Correct Answer: C
Rationale: Assessing the client's learning style. Tailoring teaching to the client's learning preferences enhances understanding.
A young adult client is scheduled for her first debridement of a second-degree burn of the left arm.
It is MOST important for the nurse to take which of the following actions?
- A. Assemble all necessary supplies and medications.
- B. Plan adequate time for the dressing change and provide emotional support.
- C. Prepare the client and family for the pain the client will experience during and after the procedure.
- D. Limit visitation prior to the procedure to reduce stress.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) appropriate, but is not a high priority (2) correct-planning for burn wound treatment should include organizing and planning to spend time not only on the mechanics of the procedure, but on providing the emotional support necessary for the client (3) appropriate, but is not a high priority (4) appropriate, but is not a high priority
During the second session of individual therapy, a client sits quietly with arms folded and eyes cast down.
Which of the following statements by the nurse is BEST?
- A. What is the weather like outside?
- B. Do you not want to talk with me today?
- C. Are you cold sitting here?
- D. You seem to be feeling sad today.
Correct Answer: D
Rationale: Strategy: 'BEST' indicates that this is a priority question. Remember therapeutic communication. (1) is used to get client comfortable, but would not help to focus on what is important (2) focusing on client's difficulty speaking may make him defensive and block communication (3) concrete questions will encourage client to give yes/no answers, factual answers may block communication of feelings (4) correct-reflection allows client to verbalize feelings
A ten-year-old child with leukemia has a large burn on her arm and the burn appears to be oily. The client states that she touched a hot pan, and her mother put cooking fat on it so it would not blister.
The nurse should
- A. document the findings in the chart.
- B. call the physician immediately to report the injury.
- C. teach the client that oil holds germs and makes infection more likely.
- D. wash the burn with soap and water to remove the oil.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) does not address the immediate problem of cleansing the wound (2) unnecessary (3) does not address the immediate problem of cleansing the wound (4) correct-because leukemic clients are immunosuppressed, they are more susceptible to infections; cooking fat applied to an open wound increases the possibility of infection; burns should be rinsed immediately with tap water to reduce the heat in the burn