Nokea
If your patient is acutely psychotic, which of the following independent nursing interventions would not be appropriate?
- A. Conveying calmness with one on one interaction
- B. Recognizing and dealing with your own feelings to prevent escalation of the patient's anxiety level
- C. Encourage client participation in group therapy
- D. Listen and identify causes of their behavior
Correct Answer: C
Rationale: Acutely psychotic patients will disrupt group activities.
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A patient has recently been prescribed (Norvasc). Which of the following side effect/s should the patient specifically watch out for?
- A. Hypotension and Angina
- B. Hypertension
- C. Lower extremity edema
- D. Peripheral sensory loss and SOB
Correct Answer: A
Rationale: Both angina and hypotension are associated with Norvasc's side effects.
Who should receive the hepatitis A vaccine?
- A. children who are 18 months of age
- B. infants, who should receive the vaccination at birth
- C. people who travel to other countries
- D. individuals who might come into contact with blood
Correct Answer: C
Rationale: Hepatitis A is for individuals who travel or persons with chronic liver disease. Infants receive the hepatitis B vaccine at birth. DTaP is administered at 18 months of age. Individuals who come into contact with blood should be immunized against hepatitis B.
Which of the following home-care strategies is most likely to negatively impact the body image of a client with Cushing's syndrome?
- A. providing safety measures to prevent falls
- B. taking medications as prescribed
- C. wearing a medical ID indicating Cushing's syndrome
- D. having regular health assessments
Correct Answer: C
Rationale: All of the strategies listed are included in home care for the client with Cushing's syndrome. Choice 3 is the best answer because wearing a medical ID is a visible sign that something is wrong and a constant reminder to the client that he or she has a loss of body function. Choice 1 might enhance body image because it prevents falls that could cause further injury and debilitation. Taking medications as prescribed should enhance body image because it decreases the symptoms present. Having regular health assessments indicates an enhanced body image because it signals the desire to take care of the body and keep it at its best.
A 93 year-old female with a history of Alzheimer's Disease gets admitted to an Alzheimer's unit. The patient has exhibited signs of increased confusion and limited stability with gait. Moreover, the patient is refusing to use a w/c. Which of the following is the most appropriate course of action for the nurse?
- A. Recommend the patient remain in her room at all times.
- B. Recommend family members bring pictures to the patient's room.
- C. Recommend a speech therapy consult to the doctor.
- D. Recommend the patient attempt to walk pushing the w/c for safety.
Correct Answer: B
Rationale: Stimulation in the form of pictures may decrease signs of confusion.
Which of the following solutions is routinely used to flush an IV device before and after the administration of blood to a client?
- A. 0.9% sodium chloride
- B. 5% dextrose in water solution
- C. sterile water
- D. Heparin sodium
Correct Answer: A
Rationale: Normal saline (0.9% sodium chloride) is isotonic and safe for flushing IV lines before and after blood administration, preventing cell lysis or clotting.