Nokea
The nurse asks a client with a history of alcoholism about recent drinking behavior. The client states 'I didn't hurt anyone. I just like to have a good time, and drinking helps me to relax.' The client is using which defense mechanism?
- A. Denial
- B. Projection
- C. Intellectualization
- D. Rationalization
Correct Answer: D
Rationale: Rationalization. The client justifies drinking by providing acceptable explanations for unacceptable behavior.
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A patient with effective pain relief.
Which of the following nursing actions is MOST important to provide a patient with effective pain relief?
- A. Teach the patient about his pain.
- B. Establish a trusting relationship with the patient.
- C. Determine how various relaxation techniques affect the pain.
- D. Provide alternative measures to relieve pain.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not most important (2) correct-necessary to work with patient to identify interventions to relieve pain (3) part of intervention and evaluation phase (4) only a portion of interventions used to relieve pain
An adult is on a clear liquid diet. Which food should the nurse offer him?
- A. A milkshake
- B. Fruited gelatin
- C. Sherbet
- D. Apple juice
Correct Answer: D
Rationale: Apple juice is a clear liquid, appropriate for a clear liquid diet. Milkshakes and sherbet contain dairy, and fruited gelatin may have solids, making them unsuitable.
Which contraindication should the nurse assess for prior to giving a child immunizations?
- A. Mild cold symptoms
- B. Chronic asthma
- C. Depressed immune system
- D. Allergy to eggs
Correct Answer: C
Rationale: Depressed immune system. Children who have a depressed immune system related to HIV or chemotherapy should not be given routine immunizations.
A two-year-old who is one-day postoperative.
The mother of a two-year-old who is one-day postoperative tells the nurse, 'My child is so restless and overactive.' The nurse should
- A. direct the LPN/LVN to obtain the child's vital signs.
- B. ask the mother if the child's sutures are still intact.
- C. tell the nursing assistant to take the child for a walk.
- D. check to see when the child last received pain medication.
Correct Answer: D
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? Yes. Determine the best assessment. (1) no indication that there are any problems (2) passing the buck (3) implementation, should first assess (4) correct-young children typically become restless and overactive if in pain, grimacing, clenching teeth, rocking, and aggressive behavior may also be observed
The nurse is caring for an adult who has myasthenia gravis and is prescribed neostigmine. Which drug should the nurse plan to have readily available because the client is taking neostigmine?
- A. Atropine
- B. Vitamin K
- C. Protamine sulfate
- D. Calcium gluconate
Correct Answer: A
Rationale: Neostigmine, a cholinesterase inhibitor, can cause cholinergic crisis; atropine, an anticholinergic, is the antidote to reverse excessive muscarinic effects.