Nokea
A college student was in a motor vehicle accident six months ago. Although he was minimally injured, his friend was killed. The client comes to Student Health Services with complaints of not being able to study, not sleeping, and thinking he's 'going crazy.'
It is MOST important for the nurse to
- A. perform a complete physical and social history.
- B. obtain a complete drug and alcohol history, including reports from a drug screen.
- C. review the significant events of the last year.
- D. explore how he coped with the motor vehicle crash and his friend's death.
Correct Answer: D
Rationale: Strategy: Determine the outcome of each answer choice. (1) not most important initially (2) not most important initially (3) not most important initially (4) correct-initially obtaining focused information about a very traumatic event is helpful and provides the nurse with an opportunity to understand how this client has coped with a tragedy that has made him vulnerable
You may also like to solve these questions
Which of the following statements, if made to the nurse, indicates parental understanding about the cause of their newborn's diagnosis of cystic fibrosis (CF)?
- A. The gene came from my husband's side of the family.
- B. The gene came from my wife's side of the family.
- C. There is a 50 percent chance that our next child will have the disease.
- D. Both of us carry a recessive trait for cystic fibrosis.
Correct Answer: D
Rationale: cystic fibrosis is inherited by an autosomal recessive trait
The nurse is caring for a client who is receiving a continuous IV infusion of dopamine for hypotension. Which of the following findings would be of GREATest concern to the nurse?
- A. Heart rate of 100 bpm.
- B. Blood pressure of 90/60 mmHg.
- C. Urine output of 20 mL/hour.
- D. Respiratory rate of 18 breaths/min.
Correct Answer: C
Rationale: Urine output of 20 mL/hour indicates oliguria, a serious complication of dopamine, suggesting inadequate renal perfusion despite treatment for hypotension. Options A, B, and D are less concerning: heart rate 100 bpm and blood pressure 90/60 mmHg are expected, and respiratory rate 18 breaths/min is normal.
Twenty-four hours after abdominal surgery.
Which of the following plans would be a nursing priority to prevent complications of flatulence?
- A. Encourage the client to drink carbonated beverages daily.
- B. Instruct the client to turn from side to side.
- C. Encourage the client to do leg exercises in bed.
- D. Assist the client to walk in the hall every 2 hours.
Correct Answer: D
Rationale: Strategy: Answers are all implementations. Determine the outcome of each answer choice. Is it desired? (1) increasing carbonated beverages will increase flatus (2) will prevent postoperative complications, but not flatulence (3) does not address flatulence (4) correct-will increase peristalsis, decreasing the development of flatus
Which of the following nursing approaches would be MOST appropriate to use while administering an oral medication to a four-month-old?
- A. Place the medication in 45 cc of formula.
- B. Place the medication in an empty nipple and allow the infant to suck.
- C. Place the medication in a full bottle of formula.
- D. Administer the medication using a plastic syringe, with the infant in the reclining position.
Correct Answer: B
Rationale: is a convenient method for administering medications to an infant
An elderly alcoholic client has been receiving a long-acting benzodiazepine (Librium) for two days for symptom management and reduction. The client states: 'Get those bugs off of me and clean them out of here.'
The nurse knows the client is exhibiting symptoms of
- A. a reaction to the sedative medication.
- B. a worsening course of the withdrawal syndrome.
- C. an exacerbation of the schizophrenia process.
- D. the process of aging and the effects of delirium.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) client has been medicated with benzodiazepines and did not experience untoward reactions (2) correct-client has most probably progressed to another level of abstinence withdrawal from polypharmacy chemical dependence; characteristic symptoms include tremors, increased heart rate, and fever, as well as psychological problems of confusion, delusions, and hallucinations (3) schizophrenic client usually experiences an episode of auditory hallucinations, not visual or tactile hallucinations (4) combination effect of the normal aging process and dementia could precipitate a similar reaction; however, the normal aging process does not produce delirium, but rather dementia