Nokea
The nurse is caring for a client scheduled to receive electroconvulsive therapy (ECT). Which is the priority nursing action while caring for this client during the treatment?
- A. monitor the airway and be prepared to provide suction if needed
- B. continuously observe vital signs and cardiac function on the monitor
- C. provide support and safe positioning to the client's arms and legs during the seizure
- D. record the type, frequency, duration, and amount of movement induced by the seizure
Correct Answer: A
Rationale: Airway management is the priority during ECT due to the risk of aspiration or respiratory compromise during induced seizures.
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When planning the care of the client diagnosed with thromboangiitis obliterans (Buerger's disease), the nurse incorporates information on which support service to best help the client cope with the lifestyle changes that are needed to control the disease process?
- A. Consult with a dietician
- B. Pain management clinic
- C. Smoking cessation program
- D. Referral to a medical social worker
Correct Answer: C
Rationale: Smoking is highly detrimental to the client with Buerger's disease, and clients are recommended to stop completely. Because smoking is a form of chemical dependency, referral to a smoking cessation program may be helpful for many clients. For many clients, symptoms are relieved or alleviated when smoking stops. None of the remaining options are directly related to the physiology associated with this condition.
The nurse is obtaining a health history from an adolescent. Which statement by the adolescent indicates a need for follow-up assessment and intervention?
- A. When I get stressed out about school, I just like to be alone.
- B. I find myself very moody. I'm happy one minute and crying the next.
- C. I don't eat any fatty foods, and I've already lost 8 pounds in 2 weeks.
- D. I can't seem to wake up in the morning. I would sleep until noon if I could.
Correct Answer: C
Rationale: During the adolescent period, there is a heightened awareness of body image and peer pressure to go on excessively restrictive diets. The extreme limitation of omitting all fat in the diet and losing weight during a time of growth suggests inadequate nutrition and a possible eating disorder. The remaining options are normal behaviors or feelings that occur during adolescence.
A client reports having difficulty concentrating and outbursts of anger, as well as feeling 'keyed up' all the time. The client reveals that the behaviors began soon after witnessing the murder of a good friend. The nurse should suspect which stressor before communicating with the client?
- A. Social phobia
- B. Panic disorder
- C. Post-traumatic stress disorder (PTSD)
- D. Obsessive-compulsive disorder (OCD)
Correct Answer: C
Rationale: PTSD is a response to an event that would be markedly distressing to almost anyone. Characteristic symptoms include a sustained level of anxiety, difficulty sleeping, irritability, difficulty concentrating, and outbursts of anger. Panic disorders and social phobia are characterized by a specific fear of an object or situation. OCD involves some repetitive thoughts or behaviors.
A newborn male infant is diagnosed with an undescended testicle (cryptorchidism), and these findings are shared with the parents. The parents ask questions about the condition. The nurse should respond to the parents that which condition can occur and have a psychosocial impact if the undescended testicle is not corrected?
- A. Atrophy
- B. Infertility
- C. Malignancy
- D. Feminization
Correct Answer: B
Rationale: Infertility can occur in males with this condition because proper function of the testes in producing fertile sperm depends on a temperature of less than 98.6°F (37.0°C). The psychological effects of an 'empty scrotum' could affect the client's perception of self and the ability to reproduce. Options 1 and 3 are possible physical consequences of a failure to treat cryptorchidism rather than psychosocial consequences. Because all of the hormones that are responsible for secondary sex characteristics continue to be secreted directly into the bloodstream, option 4 is not correct.
A client has just given birth to a newborn who has a cleft lip and palate. When planning to talk with the client, the nurse recognizes that the client needs to first work through which emotion before maternal bonding can occur?
- A. Guilt
- B. Grief
- C. Anger
- D. Depression
Correct Answer: B
Rationale: The nurse should recognize that a mother will go through the grief process after giving birth to a child with a birth defect. After the grief process, the mother can begin to focus on bonding with the infant. The remaining options are incorrect because they are each only one component of the grief process.