Nokea
Primary nursing diagnoses for the antisocial client are:
- A. Alteration in perception and altered self-concept
- B. Impaired social interaction, ineffective individual coping, and altered self-concept
- C. Altered communication processes and altered recreational patterns
- D. Altered body image and altered thought processes
Correct Answer: B
Rationale: This answer is incorrect. Perception is not altered because the client is not psychotic. This answer is correct. The antisocial client lacks responsibility, accountability, and social commitment; has impaired problem-solving ability; tends to overuse defense mechanisms; lies and steals; and is often grandiose concerning self. This answer is incorrect. Altered communication processes do not characterize this client. The antisocial person communicates well and tends to have a charming personality. This answer is incorrect. Altered thought processes refer to delusional thinking, which is bizarre and fixed, and do not characterize this client.
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When planning care for the passive-aggressive client, the nurse includes the following goal:
- A. Allow the client to use humor, because this may be the only way this client can express self.
- B. Allow the client to express anger by using 'I' messages, such as 'I was angry when . . .,' etc.
- C. Allow the client to have time away from therapeutic responsibilities.
- D. Allow the client to give excuses if he forgets to give staff information.
Correct Answer: B
Rationale: Ceasing to use humor and sarcasm is a more appropriate goal, because this client uses these behaviors covertly to express aggression instead of being open with anger. Use of 'I' messages demonstrates proper use of assertive behavior to express anger instead of passive-aggressive behavior. Client is expected to complete share of work in therapeutic community because he has often obstructed other's efforts by failing to do his share. Client has used conveniently forgetting or withholding information as a passive-aggressive behavior, which is not acceptable.
Which of the following nursing interventions has the highest priority for the client scheduled for an intravenous pyelogram?
- A. Providing the client with a favorite meal for dinner
- B. Asking if the client has allergies to shellfish
- C. Encouraging fluids the evening before the test
- D. Telling the client what to expect during the test
Correct Answer: B
Rationale: Intravenous pyelogram uses iodine-based contrast, which can cause allergic reactions, especially in clients with shellfish/iodine allergies. Identifying allergies is the highest priority for safety.
Which obstetrical client is most likely to have an infant with respiratory distress syndrome?
- A. A 28-year-old with a history of alcohol use during the pregnancy
- B. A 24-year-old with a history of diabetes mellitus
- C. A 30-year-old with a history of smoking during the pregnancy
- D. A 32-year-old with a history of pregnancy-induced hypertension
Correct Answer: B
Rationale: Maternal diabetes increases the risk of neonatal respiratory distress syndrome due to impaired surfactant production from hyperglycemia. Alcohol, smoking, and hypertension are less directly linked.
The physician orders fluoxetine (Prozac) for a depressed client. Which of the following should the nurse remember about fluoxetine?
- A. Because fluoxetine is a tricyclic antidepressant, it may precipitate a hypertensive crisis.
- B. The therapeutic effect of the drug occurs 2-4 weeks after treatment is begun.
- C. Foods such as aged cheese, yogurt, soy sauce, and bananas should not be eaten with this drug.
- D. Fluoxetine may be administered safely in combination with monoamine oxidase (MAO) inhibitors.
Correct Answer: B
Rationale: Fluoxetine is not a tricyclic antidepressant. It is an atypical antidepressant. This statement is true. These foods are high in tyramine and should be avoided when the client is taking MAO inhibitors. Fluoxetine is not an MAO inhibitor. Fatal reactions have been reported in clients receiving fluoxetine in combination with MAO inhibitors.
A client with a history of pulmonary embolism is admitted with complaints of chest pain. The nurse should give priority to:
- A. Administering anticoagulants
- B. Monitoring respiratory status
- C. Administering pain medication
- D. Monitoring blood pressure
Correct Answer: A
Rationale: Anticoagulants prevent further clot formation in pulmonary embolism, making them the priority to reduce complications.