Nokea
The nurse is admitting a client who recently underwent a bilateral adrenalectomy. Which intervention is essential for the nurse to include in the client's plan of care?
- A. Prevent social isolation.
- B. Consider occupational therapy.
- C. Discuss changes in body image.
- D. Avoid stress-producing situations.
Correct Answer: D
Rationale: Adrenalectomy can lead to adrenal insufficiency. Adrenal hormones are essential to maintaining homeostasis in response to stressors. None of the remaining options are essential interventions specific to this client's problem.
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The nurse is preparing to care for an infant diagnosed with pertussis. Which priority problem should the nurse address when planning care?
- A. Infection
- B. Fluid overload
- C. Impaired sleep patterns
- D. Inability to expectorate secretions
Correct Answer: D
Rationale: The priority problem for the child with pertussis relates to adequate air exchange. Because of the copious, thick secretions that occur with pertussis and the small airways of an infant, air exchange is critical. Infection is an important consideration, but airway is the priority. A deficient fluid volume is more likely to occur in this infant because of the thick secretions and vomiting. Sleep patterns may be disturbed because of the coughing, but this is not the critical issue.
The nurse is planning care for an infant who has a diagnosis of hypertrophic pyloric stenosis and is scheduled for surgery. Which intervention should the nurse include to meet the infant's preoperative needs?
- A. Administer enemas until returns are clear.
- B. Provide the mother privacy to breast-feed every 2 hours.
- C. Monitor the intravenous (IV) infusion, intake, output, and weight.
- D. Provide small, frequent feedings of glucose, water, and electrolytes.
Correct Answer: C
Rationale: Preoperatively, important nursing responsibilities for the child with hypertrophic pyloric stenosis include monitoring the IV infusion, intake, output, and weight and obtaining urine specific gravity measurements. Additionally, weighing the infant's diapers provides information regarding output. Enemas until clear would further compromise the fluid volume status. Preoperatively, the infant receives nothing by mouth unless otherwise prescribed by the primary health care provider.
Which items should the nurse plan to provide to optimally maintain the integrity of a set of arterial blood gas measurements?
- A. A syringe that contains a preservative
- B. A heparinized syringe and a bag of ice
- C. A heparinized syringe and a preservative
- D. A syringe that contains a preservative and a bag of ice
Correct Answer: B
Rationale: The arterial blood gas sample is obtained using a heparinized syringe. The sample of blood is placed on ice and sent to the laboratory immediately. A preservative is not used.
A client who was a victim of a gunshot incident states, 'I feel like I am losing my mind. I keep hearing the gunshots and seeing my friend lying on the ground.' Which strategy should the nurse include when initially formulating a therapeutic relationship?
- A. Teaching the client a variety of relaxation techniques
- B. Asking the psychiatrist to prescribe appropriate medication
- C. Encouraging the client to talk about the incident and feelings related to it
- D. Encouraging the client to think about just how lucky he or she is to still be alive
Correct Answer: C
Rationale: When developing a therapeutic relationship, it is important to acknowledge and validate the client's feelings. Although teaching the client relaxation techniques may be helpful at some point, it is not related to the subject of the question. Options 2 and 4 are nontherapeutic techniques, and they do not promote a therapeutic relationship.
The nurse is preparing discharge plans for a hospitalized client who attempted suicide. Which intervention should the nurse include in the plan as an immediate resource?
- A. Scheduling weekly follow-up appointments
- B. Establishing contracts with available crisis resources
- C. Encouraging family and friends to be with the client at all times
- D. Providing phone numbers for the hospital and primary health care provider
Correct Answer: B
Rationale: Crisis times may occur between appointments. Contracts facilitate a client's feeling of responsibility for keeping a promise, which gives him or her control. Providing phone numbers will not ensure available and immediate crisis intervention. Family and friends cannot always be present.