Nokea
The client is prescribed clozapine (Clozaril), and the nurse plans to educate them about its purpose. Which statement should the nurse provide?
- A. It will help you function better in the community.
- B. The medication will help you think more clearly.
- C. You will be able to cope with your symptoms.
- D. It will improve your grooming and hygiene.
Correct Answer: B
Rationale: The correct answer is B: "The medication will help you think more clearly." This is the most appropriate statement to educate the client about clozapine. Clozapine is an antipsychotic medication used to treat schizophrenia and helps with cognitive symptoms such as disorganized thinking. Choice A is too vague and doesn't specify the medication's intended effect. Choice C is too general and doesn't focus on cognitive improvement. Choice D is incorrect as clozapine does not specifically target grooming and hygiene but rather cognitive symptoms.
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The client has acute pancreatitis. Which nursing intervention is the highest priority?
- A. Administer pain medication as prescribed.
- B. Monitor the client's serum amylase and lipase levels.
- C. Encourage oral intake of clear liquids.
- D. Assess the client's bowel sounds every 4 hours.
Correct Answer: A
Rationale: The correct answer is A: Administer pain medication as prescribed. This is the highest priority because acute pancreatitis is a painful condition, and managing pain is crucial for the client's comfort and well-being. Pain control also helps reduce stress on the pancreas and can aid in preventing complications.
Choice B is incorrect because while monitoring serum amylase and lipase levels is important in diagnosing pancreatitis and assessing response to treatment, it is not the highest priority intervention.
Choice C is incorrect as encouraging oral intake of clear liquids may exacerbate pancreatitis symptoms and lead to further complications.
Choice D is incorrect as assessing bowel sounds, while important for monitoring gastrointestinal function, is not the highest priority in the acute management of pancreatitis.
Which assessment finding indicates a client's readiness to leave the nursing unit for a bronchoscopy?
- A. Client denies allergies to contrast media.
- B. Skin prep to insertion site completed.
- C. On-call sedation administered.
- D. Oxygen at 2 L/minute via nasal cannula.
Correct Answer: C
Rationale: Rationale: Option C, on-call sedation administered, is the correct answer because sedation is essential for bronchoscopy to ensure the client is comfortable and cooperative during the procedure. Sedation helps reduce anxiety and discomfort, making the procedure more tolerable. Options A, B, and D are incorrect as they do not directly indicate readiness for the procedure. Denying allergies to contrast media (A) is important but not specific to bronchoscopy readiness. Skin prep completion (B) is part of the pre-procedure preparation but does not confirm readiness. Oxygen administration (D) is a routine care measure and does not indicate readiness for bronchoscopy.
A client with newly diagnosed diabetes mellitus is being discharged home. Which statement indicates the client understands the instructions about managing blood glucose levels?
- A. I will test my blood glucose level once a week.
- B. I should eat a snack if my blood glucose is 70 mg/dl.
- C. If I feel shaky, I should take another dose of insulin.
- D. It's okay to skip a meal if I'm not hungry.
Correct Answer: B
Rationale: The correct answer is B because eating a snack when blood glucose is 70 mg/dl helps prevent hypoglycemia. Testing blood glucose once a week (A) is not frequent enough for proper management. Taking extra insulin when shaky (C) can lead to hypoglycemia. Skipping meals (D) can cause unstable blood glucose levels.
A highly successful individual presents to the community mental health center complaining of sleeplessness and anxiety over their financial status. What action should the nurse take to assist this client in diminishing their anxiety?
- A. Encourage them to initiate daily rituals.
- B. Reinforce the reality of their financial situation.
- C. Direct them to drink a glass of red wine at bedtime.
- D. Teach them to limit sugar and caffeine intake.
Correct Answer: D
Rationale: The correct answer is D: Teach them to limit sugar and caffeine intake.
Rationale:
1. Sugar and caffeine intake can exacerbate anxiety and interfere with sleep due to their stimulant effects.
2. Limiting these substances can help regulate the body's energy levels and reduce anxiety symptoms.
3. By teaching the client to limit sugar and caffeine intake, the nurse is addressing the root causes of the client's sleeplessness and anxiety.
Summary:
A: Encouraging daily rituals may provide structure but does not directly address the physiological effects of sugar and caffeine on anxiety.
B: Reinforcing the reality of the financial situation may increase anxiety rather than alleviate it.
C: Drinking red wine at bedtime is not a recommended solution for managing anxiety and sleeplessness.
Which intervention should the nurse implement to enhance the efficacy of the client's asthma medication therapy?
- A. Administer the albuterol inhaler before other inhaled medications.
- B. Provide oxygen via nasal cannula at 2 liters/minute.
- C. Encourage the client to drink three liters of fluids daily.
- D. Keep the client upright during nebulizer therapy.
Correct Answer: A
Rationale: The correct answer is A: Administer the albuterol inhaler before other inhaled medications. Administering albuterol first helps open airways, allowing better absorption of subsequent medications. Option B does not directly enhance medication efficacy. Option C promotes hydration but doesn't affect medication efficacy. Option D does not specifically enhance medication therapy.