Nokea
The health team needs to realize that the compulsive concern with cleanliness that a client with severe anxiety exhibits is most likely an attempt to:
- A. Reduce his anxiety
- B. Avoid going to psychotherapy
- C. Manipulate the health team members
- D. Increase his self-image by showing higher standards than the fellow clients
Correct Answer: A
Rationale: These behaviors are attempts to relieve anxiety, as compulsive actions often serve as a coping mechanism for severe anxiety.
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During the change of shift report, a nurse writes in her notes that she suspects illegal drug use by a client assigned to her care. During the shift, the notes are found by the client's daughter. The nurse could be sued for:
- A. Libel
- B. Slander
- C. Malpractice
- D. Negligence
Correct Answer: A
Rationale: Libel involves written defamatory statements, such as unverified suspicions of drug use in notes accessible to others, potentially harming the client's reputation.
The nurse is teaching a client with a history of type 2 diabetes about foot care. The nurse should tell the client to:
- A. Inspect feet daily
- B. Soak feet in hot water
- C. Wear tight shoes
- D. Cut toenails with scissors
Correct Answer: A
Rationale: Daily foot inspection helps detect early signs of injury or infection in type 2 diabetes, preventing complications like ulcers.
A 15-year-old child is admitted to the pediatric unit with a diagnosis of thalassemia. Which of the following would be included in educating the mother and child as part of discharge planning?
- A. Give oral iron medication every day.
- B. Have the child's blood pressure monitored every week.
- C. Know the signs and symptoms of iron overload.
- D. Keep exercise at a minimum to reduce stress.
Correct Answer: C
Rationale: Oral iron supplements are contraindicated in thalassemia. Although heart failure may be an end result of this disease, this action is unnecessary. Iron overload is a potential complication of frequent blood transfusions of children with thalassemia. Children should be encouraged to pursue activities related to their exercise tolerance.
A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:
- A. Decreased blood pressure and constricted pupils
- B. Increased heart rate and increased respirations
- C. Increased respirations and increased blood pressure
- D. Anoxia and absence of the cough reflex
Correct Answer: A
Rationale: Cholinergic crisis, often from excessive anticholinesterase medication, causes parasympathetic overstimulation, leading to decreased blood pressure and constricted pupils.
The client is admitted with a diagnosis of acute pancreatitis. Which position is most comfortable for the client?
- A. Supine
- B. Prone
- C. Fowler’s
- D. Side-lying with knees flexed
Correct Answer: D
Rationale: Side-lying with knees flexed reduces pressure on the inflamed pancreas, providing comfort in acute pancreatitis. Supine, prone, and Fowler’s positions may increase discomfort.