Nokea
The nurse is planning care for a client with a diagnosis of paranoid schizophrenia. The nurse knows that questioning the client about his false ideas will
- A. cause him to defend the idea.
- B. help him clarify his thoughts.
- C. facilitate better communication.
- D. lead to a breakdown of the defense.
Correct Answer: A
Rationale: contraindicated; encourages patient to engage in further distortion of reality
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The nurse is caring for a client with a history of chronic kidney disease who is receiving epoetin alfa (Epogen). Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Hemoglobin 14 g/dL.
- B. Potassium 4.5 mEq/L.
- C. Creatinine 3.0 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: A hemoglobin of 14 g/dL is too high for epoetin alfa therapy, increasing the risk of hypertension and thrombosis, requiring dose adjustment. Options B, C, and D are expected: potassium 4.5 mEq/L and calcium 9.0 mg/dL are normal, and creatinine 3.0 mg/dL is consistent with chronic kidney disease.
A 26-year-old woman is admitted to the neurosurgery unit for the removal of a cerebellar tumor.
The nurse would expect the patient to make which of the following statements about her symptoms?
- A. I have been having difficulty with my hearing.'
- B. I lose my balance easily.'
- C. I can't tell the difference between a sweet and sour taste.'
- D. It is not easy for me to remember names and faces.'
Correct Answer: B
Rationale: Strategy: Remember physiology. (1) temporal lobe contains auditory center, loss of hearing would involve CN VIII acoustic (2) correct-cerebellum maintains balance (3) CN IX, glossopharyngeal responsible for differentiation of taste (4) not specific symptoms of cerebellum dysfunction
The nurse is reviewing the chart of a 1-day-old infant. Which of the following data requires further action?
- A. Heart rate of 128
- B. Respiratory rate of 72
- C. Hematocrit of 50%
- D. Blood glucose of 60 mg/100 mL
Correct Answer: B
Rationale: A respiratory rate of 72 is elevated for a newborn (normal 30-60 breaths/min), suggesting potential respiratory distress requiring further evaluation.
During the rehabilitative phase, the client's burns become infected with pseudomonas. The topical dressing most likely to be ordered for the client is:
- A. Silver sulfadiazine (Silvadene)
- B. Poviodine (Betadine)
- C. Mafenide acetate (Sulfamylon)
- D. Silver nitrate
Correct Answer: C
Rationale: Mafenide acetate (Sulfamylon) is particularly effective against Pseudomonas infections due to its broad-spectrum antibacterial activity and ability to penetrate eschar. Silver sulfadiazine is less effective against Pseudomonas, and povidone-iodine and silver nitrate are not the primary choices for Pseudomonas infections. Answers A, B, and D are incorrect because they are less effective for this specific infection.
A one-year-old child.
While doing a physical examination of a one-year-old child, which of the following assessments should be done by the nurse LAST?
- A. Take a rectal temperature.
- B. Auscultate the breath sounds.
- C. Auscultate the apical heart rate.
- D. Evaluate motor functions.
Correct Answer: A
Rationale: Strategy: Picture the situation. (1) correct-all invasive procedures should be done last, so as not to alter cardiopulmonary assessment of the child (2) should be done before a rectal temperature (3) should be done before a rectal temperature (4) should be done before a rectal temperature