Nokea
A client is admitted to the emergency room in severe emotional distress. The client's respirations are 42/min, and the blood gases reveal a pH of 7.5 and a PaCO2 of 34.
Initially the nurse should
- A. instruct the client to breathe into a paper bag.
- B. start an IV of D5W.
- C. administer O2.
- D. have the client place his head between his knees.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-because of hyperventilation, client is in alkalosis; having him rebreathe his own carbon dioxide will reverse his blood gas imbalance (2) does not address the problem (3) is not hypoxic (4) is done when a client feels faint
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During the physical assessment, the nurse determines the need to perform the bulge Test .
Which of the following statements, if made by the nurse, is BEST?
- A. Please lie down and extend your legs.
- B. Please bend over and touch your toes.
- C. Please hold both hands behind your back.
- D. Please bend your elbow.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-bulge Test confirms presence of fluid in the knee; client's leg should be extended and supported on the bed (2) observing curve of spine; scoliosis will cause lateral curve in the spine (3) unrelated to knee examination (4) Test s articulation of elbow
A baby boy is delivered after a rapid labor of three hours. What nursing action takes priority in the immediate newborn period?
- A. Suctioning with a bulb syringe
- B. Wrapping the baby in warm blankets
- C. Applying identification bracelets and taking footprints
- D. Assigning an APGAR score
Correct Answer: A
Rationale: Suctioning with a bulb syringe clears airways, ensuring respiratory patency, the priority in the immediate newborn period to prevent aspiration.
A client taking phenelzine (Nardil) eating another client's lunch, then complaining of headache, nausea, rapid heartbeat, and vomiting.
The nurse anticipates administering which of the following medication?
- A. Buspirone (Buspar).
- B. Fluoxetine (Prozac).
- C. Prochlorperazine (Compazine).
- D. Nifedipine (Procardia).
Correct Answer: D
Rationale: Strategy: Think about the action of each medication. (1) antianxiety; side effects include light-headedness, confusion, hypotension, palpitations (2) SSRI antidepressant; side effects include palpitation, bradycardia, nausea and vomiting (3) antiemetic; side effects include drowsiness, orthostatic hypotension (4) correct-antihypertensive; client experiencing hypertensive crisis due to ingesting tyramine; side effects include dizziness, headache, nervousness
The nurse knows which of the following would be MOST likely to help the family of an emotionally disturbed client manage behaviors at home after discharge from inpatient treatment?
- A. Refer the family to Alliance for the Mentally Ill meetings for educational programs and support groups.
- B. Provide the family with pamphlets that describe the desired action and side effects of medications the client is taking.
- C. Tell the family that it is not their fault that the client behaves inappropriately.
- D. Involve the family in the assessment of the client when s/he is first admitted to the hospital.
Correct Answer: A
Rationale: The Alliance for the Mentally Ill offers ongoing education and support groups, equipping families with skills to manage behaviors long-term. Pamphlets, reassurance, and early involvement are helpful but lack the sustained impact of a support network.
A victim of domestic violence states to the nurse, 'If only I could change and be how my companion wants me to be, I know things would be different.' Which would be the best response by the nurse?
- A. The violence is temporarily caused by unusual circumstances, don't stop hoping for a change.
- B. Perhaps, if you understood the need to abuse, you could stop the violence.
- C. No one deserves to be beaten. Are you doing anything to provoke your spouse into beating you?
- D. Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do.
Correct Answer: D
Rationale: Batterers lose self-control because of their own internal reasons, not because of what their partner did or did not do. This clarifies that the abuser is responsible for the violence.