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In working with mental health clients who are prescribed medication that must be taken on a routine basis, it is important for education to begin when the drug therapy is initiated. One of the first steps in the teaching process is to:
- A. Explain the side effects of the medication
- B. Discuss the danger of overmedication
- C. Distribute written material to supplement verbal instructions
- D. Explore the client's perception regarding medication therapy
Correct Answer: D
Rationale: (A, B, C) The nurse must first obtain information regarding the client's perception of the medication regimen. The first step in the teaching process is to determine the client's perception.
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A client is admitted with symptoms of pseudomembranous colitis. Which finding is associated with Clostridium difficile?
- A. Diarrhea containing blood and mucus
- B. Cough, fever, and shortness of breath
- C. Anorexia, weight loss, and fever
- D. Development of ulcers on the lower extremities
Correct Answer: A
Rationale: Clostridium difficile causes pseudomembranous colitis, characterized by diarrhea with blood and mucus due to toxin-mediated inflammation of the colon.
Which of the following physician's orders would the nurse question on a client with chronic arterial insufficiency?
- A. Neurovascular checks every 2 hours
- B. Elevate legs on pillows
- C. Arteriogram in the morning
- D. No smoking
Correct Answer: B
Rationale: Neurovascular checks are a routine part of assessment with clients having this diagnosis. Elevation of the legs is contraindicated because it reduces blood flow to areas already compromised. Arteriogram is a routine diagnostic order. Smoking is highly correlated with this disorder.
The client is having electroconvulsive therapy for treatment of severe depression. Prior to the ECT,the nurse should:
- A. Apply a tourniquet to the client's arm
- B. Administer an anticonvulsant medication
- C. Ask the client if he is allergic to shellfish
- D. Apply a blood pressure cuff to the arm
Correct Answer: D
Rationale: A blood pressure cuff is applied to one limb during ECT to monitor for seizure activity (visible in the uncuffed limb). Tourniquets anticonvulsants and shellfish allergies are not relevant to ECT preparation.
A client had a hemicolectomy performed 2 days ago. Today, when the nurse assesses the incision, a small part of the abdominal viscera is seen protruding through the incision. This complication of wound healing is known as:
- A. Excoriation
- B. Dehiscence
- C. Decortication
- D. Evisceration
Correct Answer: D
Rationale: Evisceration occurs when the incision separates and the contents of the cavity spill out.
A 16-year-old client with a diagnosis of oppositional defiant disorder is threatening violence toward another child. In managing a potentially violent client, the nurse:
- A. Must use the least restrictive measure possible to control the behavior
- B. Should put the client in seclusion until he promises to behave appropriately
- C. Should apply full restraints until the behavior is under control
- D. Should allow other clients to observe the acting out so that they can learn from the experience
Correct Answer: A
Rationale: This answer is correct. Least restrictive measures should always be attempted before a client is placed in seclusion or restraints. The nurse should first try a calm verbal approach, suggest a quiet room, or request that the client take 'time-out' before placing the client in seclusion, giving medication as necessary, or restraining. This answer is incorrect. A calm verbal approach or requesting that a client go to his room should be attempted before restraining. This answer is incorrect. Restraints should be applied only after all other measures fail to control the behavior. (D Seniors) This answer is incorrect. Other clients should be removed from the area. It is often very anxiety producing for other clients to see a peer out of control. It could also lead to mass acting-out behaviors.