Nokea
The client with borderline personality disorder spends much time around the nurse's station, making numerous minor requests. The nurse interprets these behaviors as indicating which of the following?
- A. Fears of abandonment and attention seeking
- B. Enjoyment of bothering the staff
- C. Boredom suggesting the need for something to do
- D. Lack of desire for involvement in milieu activities
Correct Answer: A
Rationale: Frequent requests and presence at the nurse's station in borderline personality disorder often reflect fears of abandonment and attention-seeking behaviors, characteristic of the disorder.
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A client with a diagnosis of myasthenia gravis is prescribed pyridostigmine (Mestinon). The nurse should teach the client to take the medication:
- A. On an empty stomach.
- B. With meals to reduce side effects.
- C. At bedtime to promote sleep.
- D. As needed for muscle weakness.
Correct Answer: B
Rationale: Pyridostigmine should be taken with food to reduce gastrointestinal side effects like nausea.
Which of the following skin care instructions would be appropriate for a client receiving radiation therapy?
- A. Avoid shaving with straight-edge razors.
- B. Clean the skin daily with antibacterial soap.
- C. Apply moisturizing lotion before and after each treatment.
- D. Keep the radiated area covered with a sterile gauze dressing.
Correct Answer: A
Rationale: Avoiding straight-edge razors prevents skin irritation in the radiated area, which is sensitive.
The nurse administering a dose of scopolamine to a preoperative client should monitor the client for which common side effect of the medication?
- A. Dry mouth
- B. Diaphoresis
- C. Excessive urination
- D. Pupillary constriction
Correct Answer: A
Rationale: Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. Each of the incorrect options is the opposite of a side effect of this medication.
A client with a history of pancreatitis is admitted with abdominal pain. The nurse should expect which of the following laboratory findings?
- A. Elevated amylase and lipase.
- B. Decreased white blood cell count.
- C. Elevated hemoglobin.
- D. Decreased blood glucose.
Correct Answer: A
Rationale: Elevated amylase and lipase are hallmark laboratory findings in pancreatitis due to pancreatic enzyme release.
A postoperative client has a Jackson-Pratt drain. Which finding should the nurse report immediately?
- A. Clear, serous drainage.
- B. Bright red drainage of 50 mL in 2 hours.
- C. Slight swelling around the drain site.
- D. Drainage with a foul odor.
Correct Answer: B
Rationale: Bright red drainage suggests active bleeding, a serious complication requiring immediate reporting.