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The nurse is caring for a client with histrionic personality disorder. Which of the following findings would the nurse expect to observe?
- A. Tries to intimidate others, lacks empathy, disregards rules, and avoids consequences
- B. Exhibits attention-seeking behaviors and is overly dramatic
- C. Is overly suspicious of others' intentions and socially withdrawn
- D. Exhibits persistent compulsive behaviors and rigid perfectionism
Correct Answer: B
Rationale: Histrionic personality disorder is characterized by attention-seeking and overly dramatic behaviors. The other options describe different personality disorders.
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The practical nurse is assisting the registered nurse in preparing the room for a client with new-onset tonic-clonic seizures. It is important to ensure that what equipment is in the room? Select all that apply.
- A. Oral bite prevention device
- B. Oxygen delivery system
- C. Padding on the bed side rails
- D. Soft arm and leg restraints
- E. Suction equipment
Correct Answer: B,C,E
Rationale: Oxygen ensures adequate oxygenation during seizures, padding prevents injury from bed rails, and suction equipment clears airways if secretions accumulate. Oral bite devices are unsafe during seizures due to choking risks, and restraints are not typically used unless absolutely necessary.
The parent of an 8-year-old client asks the nurse for guidance on how to help the client cope with the recent death of the other parent. When developing a response to the parent, the nurse considers that a school-aged child is most likely to do what?
- A. React anxiously to altered daily routines
- B. Realize that death eventually affects everyone
- C. Think about the religious or spiritual aspects of death
- D. Understand that death is permanent but be curious about it
Correct Answer: D
Rationale: School-aged children (around 8 years old) typically understand death's permanence and may exhibit curiosity about it, which can guide coping strategies. A is more common in younger children. B and C are more typical of adolescents, who have more abstract thinking.
A client with atrial fibrillation is being discharged home after being stabilized with medications, including digoxin. Which client statement regarding digoxin toxicity indicates that reinforcement of the discharge education is needed?
- A. I must visit my health care provider to check my drug levels.
- B. I should report to my health care provider if I develop nausea and vomiting.
- C. I should tell my health care provider if my heart rate is below 60 beats per minute.
- D. I will need to increase my potassium intake.
Correct Answer: D
Rationale: Increasing potassium intake is incorrect and risky with digoxin, as it can affect drug levels. Other statements reflect correct understanding.
A client is admitted to the emergency room with renal calculi and is complaining of moderate to severe flank pain and nausea. The client's temperature is 100.8 degrees Fahrenheit. The priority nursing goal for this client is
- A. Maintain fluid and electrolyte balance
- B. Control nausea
- C. Manage pain
- D. Prevent urinary tract infection
Correct Answer: C
Rationale: Manage pain. The immediate goal of therapy is to alleviate the client's pain, which can be quite severe with kidney stones.
The nurse is to apply an Ace wrap to the client's right lower leg. Which action should the nurse take to ensure that the dressing is not too tight?
- A. Remove it every hour and reapply it.
- B. Check the pedal pulses.
- C. Obtain a Doppler study to determine circulation.
- D. Allow the wrap to remain in place for a minimum of 24 hours.
Correct Answer: B
Rationale: Checking pedal pulses ensures the Ace wrap does not impair circulation. Removing hourly is impractical, Doppler is excessive, and leaving for 24 hours risks missing issues.