Nokea
The nurse is caring for a client with a diagnosis of postpartum depression. Which symptom is most likely to be present?
- A. Persistent sadness
- B. Fever and chills
- C. Uterine tenderness
- D. Foul-smelling lochia
Correct Answer: A
Rationale: Postpartum depression is characterized by persistent sadness and low mood. Fever uterine tenderness and foul-smelling lochia suggest infection not depression.
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A client with a history of atrial fibrillation is admitted with complaints of palpitations. The nurse should expect the client to have:
- A. Irregular pulse
- B. Bradycardia
- C. Hypertension
- D. Chest pain
Correct Answer: A
Rationale: Atrial fibrillation causes an irregular pulse due to disorganized atrial contractions, a hallmark of the condition.
In admitting a client to the psychiatric unit, the nurse must explain the rules and regulations of the unit. A client with antisocial personality disorder makes the following remark, 'Forget all those rules. I always get along well with the nurses.' Which nursing response to him would be most effective?
- A. OK, don't listen to the rules. See where you end up.'
- B. I'm pleased that you get along so well with the staff. You must still know and abide by the rules.'
- C. It is irrelevant whether you get along with the nurses.'
- D. I'm not the other nurses. You better read the rules yourself.'
Correct Answer: B
Rationale: This answer is incorrect. A nurse should be an appropriate role model. Threats are not appropriate. No limit setting was stated. This answer is correct. The nurse made a positive statement followed by a simple, clear, concise setting of limits. This answer is incorrect. It appears to have a negative connotation. There was no limit setting. This answer is incorrect. The nurse obviously responded in a negative manner. Learning takes place more readily when one is accepted, not rejected. No limits were set.
A client with an abdominal aortic aneurysm is admitted in preparation for surgery. Which finding should be reported to the doctor?
- A. A WBC of 14,000 cu.mm
- B. Auscultation of abdominal bruit
- C. Complaints of lower back pain
- D. A platelet count of 175,000 cu.mm
Correct Answer: A
Rationale: A WBC of 14,000 cu.mm indicates possible infection or inflammation, which is concerning pre-surgery and should be reported. Abdominal bruit and lower back pain are expected with an abdominal aortic aneurysm, and a platelet count of 175,000 is normal.
A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
- A. Give fluids if the client requests them.
- B. Assess skin integrity and circulation of extremities before applying restraints and as they are removed.
- C. Measure vital signs at least every 4 hours.
- D. Release restraints every 2 hours for client to exercise.
Correct Answer: D
Rationale: Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.
A patient with a PCA pump (patient controlled analgesia) asks the nurse if he can become overdosed with pain medication using this machine. Which statement made by the nurse is correct?
- A. The machine will administer only the amount of medication needed to control pain without any action from you.'
- B. The machine has a locking device that prevents overdosing.'
- C. The machine will administer one large dose every four hours to relieve your pain.'
- D. The machine is set to deliver medication only if you need it.'
Correct Answer: B
Rationale: PCA pumps have a lockout interval and dose limits programmed to prevent overdose, ensuring safe administration of pain medication. The other statements are inaccurate: PCA requires patient action, does not deliver large doses every four hours, and is not based on ‘need’ detection.