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The nurse is caring for a client who is dying. While assessing the client for signs of impending death, the nurse observes the client for:
- A. elevated blood pressure.
- B. Cheyne-Stokes respiration.
- C. elevated pulse rate.
- D. decreased temperature.
Correct Answer: B
Rationale: Cheyne-Stokes respirations are rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea, often associated with cardiac failure. This can be a sign of impending death.
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When helping a client gain insight into anxiety, the nurse should:
- A. help relate anxiety to specific behaviors.
- B. ask the client to describe events that precede increased anxiety.
- C. instruct the client to practice relaxation techniques.
- D. confront the client's resistive behavior.
Correct Answer: B
Rationale: To gain insight, the client needs to recognize causal events. The other activities focus on recognition of anxiety.
A client with urinary tract calculi needs to avoid which of the following foods?
- A. lettuce
- B. cheese
- C. apples
- D. broccoli
Correct Answer: B
Rationale: The client with urinary tract calculi needs to avoid cheese, which has high calcium content. The other foods do not.
A client is admitted with a diagnosis of Multiple Drug Use. The nurse should plan care based on knowledge that:
- A. Multiple drug use is very uncommon
- B. People might use more than one drug to enhance the effect or relieve withdrawal symptoms
- C. Alcohol and barbiturates used together are not dangerous because one is a stimulant and the other is a depressant
- D. Assessment and intervention are easier with multiple drug use because of the synergistic effect
Correct Answer: B
Rationale: Multiple drug use is common to enhance effects or relieve withdrawal symptoms, complicating assessment and intervention due to varied drug interactions.
A 64 year-old Alzheimer's patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure?
- A. Secure the restraints to the bed rails on all extremities.
- B. Notify the physician that restraints have been placed properly.
- C. Communicate with the patient and family the need for restraints.
- D. Position the head of the bed at a 45 degree angle.
Correct Answer: C
Rationale: Both the family and the patient should have the need for restraints explained to them.
A primary belief of psychiatric mental health nursing is:
- A. most people have the potential to change and grow.
- B. every person is worthy of dignity and respect.
- C. human needs are individual to each person.
- D. some behaviors have no meaning and cannot be understood.
Correct Answer: B
Rationale: Every person is worthy of dignity and respect. Every person has the potential to change and grow. All people have basic human needs in common with others. All behavior has meaning and can be understood from the client's perspective.