Nokea
The nurse is developing a comprehensive care plan for a young woman with an eating disorder. The nurse refers this client to assertiveness skills classes. The nurse knows that this is an appropriate intervention because this client may have problems with
- A. aggressive behaviors and angry feelings.
- B. self-identity and self-esteem.
- C. focusing on reality.
- D. family boundary intrusions.
Correct Answer: B
Rationale: clients with eating disorders experience difficulty with self-identity and self-esteem, which inhibits their abilities to act assertively; some assertiveness techniques that are taught include giving and receiving criticism, giving and accepting compliments, accepting apologies, being able to say no, and setting limits on what they can realistically do rather than just doing what others want them to do
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The nurse is caring for a client with a history of epilepsy who is receiving carbamazepine (Tegretol) 200 mg PO bid. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. White blood cell count of 3,000/mm^3.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: A white blood cell count of 3,000/mm^3 indicates leukopenia, a serious side effect of carbamazepine, increasing infection risk and requiring immediate evaluation. Options B, C, and D are normal: sodium 140 mEq/L, potassium 4.0 mEq/L, and hemoglobin 13 g/dL do not indicate complications.
A young female teenager describes a brutal assault and rape to the nurse on duty. Which of the following actions should the nurse take first?
- A. Check with case manager on duty about possible police intervention.
- B. Provide an environment of concern and emotional stabilization.
- C. Clean the patient's wounds with normal saline and gauze.
- D. Recommend a good attorney to the patient.
Correct Answer: B
Rationale: Emotional support is what that patient needs most at this point in time.
The nurse should observe for side effects associated with the use of bronchodilators. A common side effect of bronchodilators is:
- A. Tinnitus
- B. Tachycardia
- C. Ataxia
- D. Hypotension
Correct Answer: B
Rationale: Tachycardia is a common side effect of bronchodilators, such as beta-agonists, due to their stimulatory effect on the sympathetic nervous system.
A client with a neurological disorder.
Which of the following nursing assessments will be MOST helpful in determining subtle changes in the client's level of consciousness?
- A. Client posturing.
- B. Glasgow coma scale.
- C. Client thinking pattern.
- D. Occurrence of hallucinations.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) indicates increased intracranial pressure (2) correct-Glasgow coma scale score best evaluates changes in a client's level of consciousness by evaluating eye-opening, motor, and verbal responses (3) more appropriate for the psychiatric client (4) more appropriate for the psychiatric client
A clinic nurse is taking a health history from a 34-year-old man newly diagnosed with Buerger's disease. The nurse would expect the client's complaints to include
- A. heart palpitations.
- B. dizziness when walking.
- C. blurred vision.
- D. digital sensitivity to cold.
Correct Answer: D
Rationale: vasculitis of blood vessels in upper and lower extremities