Nokea
The nurse assesses the use of coping mechanisms by an adolescent 1 week after the client had a motor vehicle accident resulting in multiple serious injuries. Which of these characteristics are most likely to be displayed?
- A. Ambivalence, dependence, demanding
- B. Denial, projection, regression
- C. Intellectualization, rationalization, repression
- D. Identification, assimilation, withdrawal
Correct Answer: B
Rationale: Helplessness and hopelessness may contribute to regressive, dependent behavior which often occurs at any age with hospitalization. Denying or minimizing the seriousness of the illness is used to avoid facing the worst situation. Recall that denial is the initial step in the process of working through any loss.
You may also like to solve these questions
The physician prescribes sucralfate (Carafate) 1 gm PO tid and 2 Maalox tablets tid for a 50-year-old man in the outpatient clinic.
The client asks the nurse when to take these medications. The nurse should advise the man to take
- A. the Carafate and the Maalox 1 hour ac.
- B. the Maalox 1 hour ac and the Carafate 1 hour pc.
- C. the Carafate and the Maalox 2 hours pc and hs.
- D. the Carafate 1 hour ac and the Maalox 1 hour pc.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) Maalox (antacids) decreases bonding to GI mucosa, don't give within 30 minutes of each other (2) Carafate best results on empty stomach, antacids decrease bonding to GI mucosa, so don't give within 30 minutes of each other (3) antacids decrease bonding to GI mucosa, so don't give within 30 minutes of each other (4) correct-Carafate has best results on empty stomach
A 34-year-old multipara comes to the prenatal clinic during her fifth month of pregnancy. The client complains to the nurse that her breasts are sensitive and sore.
Which of the following suggestions by the nurse is BEST?
- A. Apply warm compresses to your breasts and take two aspirin as needed.
- B. Massage your breasts with lotion and wear loose-fitting clothing.
- C. Apply cold compresses to your breasts and wear a well-fitting, supportive bra.
- D. Take a diuretic once a day and avoid touching your breasts.
Correct Answer: C
Rationale: Strategy: 'BEST' indicates priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) would increase circulation and increase discomfort, should avoid taking medications (2) not effective in decreasing discomfort (3) correct-during pregnancy there is an increase in lactiferous ducts and lobule-alveolar tissue (4) medications are to be avoided during pregnancy
A female client diagnosed with genital herpes simplex virus 2 (HSV 2) complains of dysuria, dyspareunia, leukorrhea and lesions on the labia and perianal skin. A primary nursing action with the focus of comfort should be to
- A. Suggest 3 to 4 warm sitz baths per day
- B. Cleanse the genitalia twice a day with soap and water
- C. Spray warm water over genitalia after urination
- D. Apply heat or cold to lesions as desired
Correct Answer: A
Rationale: Suggest 3 to 4 warm sitz baths per day. Frequent sitz baths may soothe the area and reduce inflammation, addressing the client's symptoms effectively.
Which of the following assessment findings would indicate to the nurse the need for more sedation in a client who is withdrawing from alcohol dependence?
- A. Steadily increasing vital signs.
- B. Mild tremors and irritability.
- C. Decreased respirations and disorientation.
- D. Stomach distress and inability to sleep.
Correct Answer: A
Rationale: Steadily increasing vital signs (e.g., heart rate, blood pressure) indicate progression toward delirium tremens, a life-threatening complication of alcohol withdrawal, necessitating additional sedation. Mild tremors, decreased respirations, or gastroinTest inal symptoms are expected or contraindicate more sedation.
A two year-old child is brought to the provider's office with a chief complaint of mild diarrhea for two days. Nutritional counseling by the nurse should include which statement?
- A. Place the child on clear liquids and gelatin for 24 hours
- B. Continue with the regular diet and include oral rehydration fluids
- C. Give bananas, apples, rice and toast as tolerated
- D. Place NPO for 24 hours, then rehydrate with milk and water
Correct Answer: B
Rationale: Current recommendations for mild to moderate diarrhea are to maintain a normal diet with fluids to rehydrate.