Nokea
A client displaying the following symptoms: elevated vital signs, hallucinations, and aggressive behavior. The client's friend says she thinks that he has been using hallucinogenic drugs.
The appropriate nursing action would be to
- A. put the client in full restraints.
- B. decrease environmental stimulation.
- C. call the security guards.
- D. administer a PRN dose of chlorpromazine (Thorazine).
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unnecessary at this time (2) correct-symptoms will subside with time and decreased stimulation (3) unnecessary at this time (4) inappropriate
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A client has developed a low inTest inal obstruction. The nurse would anticipate which of the following findings?
- A. Nausea, vomiting, abdominal distention.
- B. Explosive, irritating diarrhea.
- C. Abdominal tenderness with rectal bleeding.
- D. Midepigastric discomfort, tarry stool.
Correct Answer: A
Rationale: there is distention above the level of obstruction and initially hyperactive bowel sounds; would be no stool, as motility distal to (below) the obstruction would cease
A client had a radical mastectomy for cancer in her right breast.
After the client returns to the unit, which of the following actions, if performed by the nurse, would be MOST appropriate?
- A. Position the client on her left side with her right arm protected in a sling.
- B. Position the client on her right side with her right arm elevated.
- C. Position the client in semi-Fowler's position with her right arm elevated.
- D. Position the client in the prone position with her right arm elevated.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) sling is not necessary, arm needs to be elevated (2) right arm cannot be elevated from this position (3) correct-this position will facilitate removal of fluid from venous pathways and lymphatic system through gravity; arm is elevated to enhance circulation and prevent edema (4) prone position is not appropriate
The nurse is teaching a client how to care for a colostomy. Which factor indicates that the client needs more instruction?
- A. The client says, 'I will change the bag as soon as it gets full.'
- B. The client is observed irrigating the colostomy while sitting on the toilet.
- C. The client positions the irrigating solution container at shoulder level.
- D. The client places a chlorophyll tablet in the drainage bag.
Correct Answer: B
Rationale: Irrigating while sitting on the toilet risks contamination; irrigation should be done in a controlled setting, indicating a need for further instruction.
A client with a diagnosis of a ruptured lumbar disc.
The nurse should anticipate which of the following in assessing a client with a diagnosis of a ruptured lumbar disc?
- A. Sensation loss in an upper extremity.
- B. Clonic jerks in the affected foot.
- C. Paresthesia in the affected leg.
- D. Chorea in the upper and lower extremities.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) results from cervical lesions (2) can occur in a person who has been paralyzed from a spinal cord injury (3) correct-lumbar lesions can cause paresthesia, pain, muscle weakness, and atrophy in the lower extremities (4) is a sign of Huntington chorea, resulting from atrophy of parts of the brain
The nurse is caring for a client with a history of rheumatoid arthritis.
- A. Which symptom is expected in a client with rheumatoid arthritis?
- B. Morning stiffness lasting over 30 minutes.
- C. Pain that worsens with activity.
- D. Asymmetrical joint involvement.
- E. Rapid onset of symptoms.
Correct Answer: A
Rationale: Morning stiffness lasting over 30 minutes is a hallmark of rheumatoid arthritis due to joint inflammation. Pain improves with activity, joints are symmetrically affected, and onset is gradual.