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The nurse is caring for a client with a history of anxiety disorder.
- A. Which intervention is most effective for managing acute anxiety in a client?
- B. Administer a benzodiazepine as ordered.
- C. Encourage deep breathing exercises.
- D. Restrict the client to their room.
- E. Provide a high-stimulus environment.
Correct Answer: B
Rationale: Deep breathing exercises calm the autonomic nervous system, reducing acute anxiety effectively and non-invasively. Benzodiazepines are used cautiously, isolation increases anxiety, and high-stimulus environments worsen it.
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The physician is assessing renal function in a client with severe pancreatitis. Which laboratory finding would be the best indicator of a problem in this area?
- A. Alkaline phosphatase 20U/L
- B. Hemoglobin 14.6 g/dL
- C. BUN 28 mg/dL
- D. Creatinine 2.3 mg/dL
Correct Answer: D
Rationale: Creatinine is the most specific laboratory test for renal functioning; normal is 0.5-1.5 mg/dL. Answers A and B do not relate to the kidney, so they are incorrect. Answer C can be abnormal with kidney function but is not as specific as the creatinine, so it's incorrect.
The provisions of the law for the Americans with Disabilities Act require nurse managers to
- A. Maintain an environment free from associated hazards
- B. Provide reasonable accommodations for disabled individuals
- C. Make all necessary accommodations for disabled individuals
- D. Consider both mental and physical disabilities
Correct Answer: B
Rationale: The law is designed to permit persons with disabilities access to job opportunities. Employers must evaluate an applicant's ability to perform the job and not discriminate on the basis of a disability. Employers also must make 'reasonable accommodations.'
The nurse is monitoring a client’s EKG strip and notes coupled premature ventricular contractions greater than 10 per minute.
- A. Which medication should the nurse expect to administer for a client with coupled PVCs greater than 10 per minute?
- B. Atropine sulfate (Atropine) IV.
- C. Isoproterenol (Isuprel) IV.
- D. Verapamil (Calan) IV.
- E. Lidocaine hydrochloride (Xylocaine) IV.
Correct Answer: D
Rationale: Lidocaine is the drug of choice for frequent or coupled PVCs, as it suppresses ventricular arrhythmias that could lead to ventricular tachycardia. Atropine treats bradycardia, isoproterenol is used for heart block, and verapamil is a calcium-channel blocker for supraventricular arrhythmias.
During the first 72 hours post CVA, the nurse should position the client:
- A. Supine
- B. Semi-Fowler
- C. Left Sim's
- D. Prone
Correct Answer: B
Rationale: Semi-Fowler's position (30-45 degrees) reduces intracranial pressure and promotes venous drainage in the acute phase post-stroke.
A client admitted to the psychiatric unit claims to be the 'Son of God' and insists that he will not be confined by 'mere mortals.' The most likely explanation for the client's delusions is:
- A. A religious conversion
- B. A stressful event
- C. Low self-esteem
- D. Overwhelming anxiety
Correct Answer: C
Rationale: Delusions of grandeur, like claiming to be the 'Son of God,' often stem from low self-esteem, compensating with inflated self-perception. Religious conversion, stress, or anxiety are less likely causes.