Nokea
How many drops per minute would you administer when the doctor's order states that the client should receive 1 liter of fluid over 8 hours and the intravenous set delivers 20 gtts per cc?
- A. 31 gtts
- B. 42 gtts
- C. 48 gtts
- D. 51 gtts
Correct Answer: A
Rationale: 1 L = 1000 mL; 1000 mL / 8 hr = 125 mL/hr; 125 mL x 20 gtts/mL / 60 min = 31.25 gtts/min, rounded to 31 (A).
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The belief stated in the previous question is more common among which of the following ethnic groups?
- A. Hispanic
- B. Caucasian
- C. Asian
- D. African American
Correct Answer: D
Rationale: This belief is notably prevalent among African Americans, per cultural studies.
Your patient, who has reported domestic violence, now tells you she is going home with her husband because he has apologized and says he is taking her to Hawaii on a romantic vacation. Which statement best helps you understand her actions?
- A. Her husband has received treatment for anger management.
- B. This is the honeymoon phase of the abuse cycle.
- C. This is the resolution phase of the family crisis.
- D. She mistakenly reported domestic violence.
Correct Answer: B
Rationale: The honeymoon phase is part of the domestic violence cycle when the abuser shows repentance for his violence. The patient remains hopeful, but without treatment the cycle will continue.
A patient was admitted 48 hours ago for injuries sustained while intoxicated. The patient is shaky, irritable, anxious, and diaphoretic. The pulse rate is 130 beats per minute. The patient shouts, 'Bugs are crawling on my bed. I’ve got to get out of here.' What is the most accurate assessment of the situation? The patient:
- A. is attempting to obtain attention by manipulating staff.
- B. may have sustained a head injury before admission.
- C. has symptoms of alcohol withdrawal delirium.
- D. is having a recurrence of an acute psychosis.
Correct Answer: C
Rationale: The correct answer is C: The patient has symptoms of alcohol withdrawal delirium. The presentation of shakiness, irritability, anxiety, diaphoresis, elevated heart rate, and hallucinations ('bugs are crawling on my bed') are classic signs of alcohol withdrawal delirium. Delirium tremens, a severe form of alcohol withdrawal, typically occurs 48-72 hours after the last drink and can be life-threatening. This patient's symptoms are consistent with the timeline and manifestations of alcohol withdrawal, requiring immediate medical intervention.
Incorrect answers:
A: Manipulating staff for attention is unlikely given the severity of the symptoms and the potential life-threatening nature of alcohol withdrawal delirium.
B: Head injury would not typically present with these specific symptoms and timeline.
D: Acute psychosis would not typically manifest with these specific symptoms in the context of alcohol intoxication and withdrawal.
The nurse demonstrates an appropriate use of outcome measurements on a mental health unit when:
- A. Requiring a client's caregiver to attend a discharge planning meeting prior to the client's release to home.
- B. Reassigning a client's activity level based on his demonstration of disregard of appropriate social boundaries.
- C. Providing the client with clean linen according to the schedule established by the facility.
- D. Permitting the son of an Asian-American client to bring some ethnic foods to his father.
Correct Answer: B
Rationale: The correct answer is B because reassigning a client's activity level based on his demonstration of disregard of appropriate social boundaries demonstrates using outcome measurements effectively in mental health care. This shows that the nurse is monitoring the client's behavior and adjusting the care plan accordingly to promote positive outcomes.
A is incorrect because requiring a caregiver to attend a discharge planning meeting does not directly relate to outcome measurements for the client's mental health progress.
C is incorrect because providing clean linen according to a schedule does not demonstrate the use of outcome measurements for mental health assessment and intervention.
D is incorrect because permitting the son to bring ethnic foods does not directly relate to monitoring and adjusting the client's care plan based on observed behaviors.
The primary advantage of a heterogeneous therapeutic group is that:
- A. There will be a variety of backgrounds represented in the group.
- B. Individuals will be expected to function outside their comfort zone.
- C. An opportunity to examine experiences from varied points of view will exist.
- D. Members will see that they are not alone and that others have problems as well.
Correct Answer: C
Rationale: The correct answer is C because a heterogeneous therapeutic group allows members to examine their experiences from varied points of view. This can lead to greater insight, empathy, and understanding among group members. By hearing different perspectives, individuals can gain new insights into their own struggles and learn from others' experiences. This process can enhance personal growth, promote tolerance, and foster a sense of community within the group.
Choices A, B, and D are incorrect because while they may be potential advantages of a therapeutic group, they do not specifically address the primary advantage of a heterogeneous group, which is the opportunity to examine experiences from varied points of view. Choice A focuses on diversity in backgrounds, choice B on stepping outside comfort zones, and choice D on creating a sense of solidarity among group members. However, these advantages are not as directly related to the main benefit of a heterogeneous group as choice C.