Nokea
The client is diagnosed with a pleural effusion. Which intervention should the nurse anticipate?
- A. Insertion of a chest tube
- B. Thoracentesis
- C. Bronchoscopy
- D. Nebulizer treatment
Correct Answer: B
Rationale: Thoracentesis is used to remove fluid from a pleural effusion, relieving respiratory distress. Chest tubes are for pneumothorax or persistent effusions, bronchoscopy is diagnostic, and nebulizers are irrelevant.
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A behavior-modification program has been started for an adolescent with oppositional defiant disorder. Which statement describes the use of behavior modification?
- A. Distractors are used to interrupt repetitive or unpleasant thoughts.
- B. Techniques using stressors and exercise are used to increase awareness of body defenses.
- C. A system of tokens and rewards is used as positive reinforcement.
- D. Appropriate behavior is learned through observing the action of models.
Correct Answer: C
Rationale: Behavior modification for oppositional defiant disorder often uses a token economy system, where positive behaviors are reinforced with rewards to encourage compliance.
The nurse is caring for a client with a history of asthma who is receiving Albuterol (Proventil). The nurse should monitor the client for:
- A. Tachycardia
- B. Hypotension
- C. Hypokalemia
- D. Hyperglycemia
Correct Answer: A
Rationale: Albuterol, a beta-agonist, commonly causes tachycardia as a side effect due to sympathetic stimulation. Hypotension, hypokalemia, and hyperglycemia are less frequent.
A client with a history of breast cancer is admitted with complaints of lymphedema. The nurse should give priority to:
- A. Providing compression therapy
- B. Administering pain medication
- C. Monitoring blood pressure
- D. Administering chemotherapy
Correct Answer: A
Rationale: Compression therapy reduces swelling in lymphedema post-breast cancer, improving comfort and function.
The nurse observes a client crying quietly. She has just experienced a spontaneous abortion at nine weeks' gestation. An appropriate response by the nurse would be:
- A. It must be God's will and probably is for the best.'
- B. This must be a difficult time for you. Would you like to talk about it?'
- C. I'm sure your other children will be a comfort for you.'
- D. Don't worry, you're still young. If I were you I'd just try again.'
Correct Answer: B
Rationale: This response is nontherapeutic because it belittles the client's response and gives a meaningless rationalization. This response acknowledges the client's feelings and demonstrates the therapeutic offering of self by the nurse. This response is nontherapeutic because it does not focus on the client's feelings and offers false reassurance. This response is nontherapeutic because it belittles the client's feelings and offers her advice.
The client is admitted with a diagnosis of abruptio placenta. Which complication is most likely to occur?
- A. Fetal distress
- B. Maternal hemorrhage
- C. Both A and B
- D. Neither A nor B
Correct Answer: C
Rationale: Abruptio placenta causes placental separation leading to fetal distress (from hypoxia) and maternal hemorrhage (from bleeding). Both are common and serious complications.