Nokea
The nurse is talking with a client with obsessive-compulsive disorder. When the client performs ritualistic behaviors, the nurse should recognize that the client
- A. is hearing voices
- B. is trying to control feelings of anger
- C. has an intense desire to control the environment
Correct Answer: C
Rationale: Ritualistic behaviors in OCD are driven by an intense need to control the environment or reduce anxiety through repetitive actions. They are not related to hearing voices or controlling anger, which are more associated with other disorders.
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The nurse is monitoring clients before and after scheduled procedures. Follow-up would be required if the nurse places a client in which position?
- A. Fowler position after a cardiac catheterization via femoral entry
- B. Right side-lying position after a percutaneous liver biopsy
- C. Sims position before a soapsuds enema
- D. Supine position after a lumbar puncture
Correct Answer: D
Rationale: After a lumbar puncture, clients should remain supine for several hours to prevent cerebrospinal fluid leakage and headaches. The right side-lying position is correct post-liver biopsy to prevent bleeding, and Sims position is appropriate for an enema.
The nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease and pneumonia. The nurse notes that the client has become disoriented and restless and becomes concerned that the client may have impaired oxygenation due to poor secretion clearance. Which is the nurse’s priority action?
- A. Administer lorazepam 1 mg IM
- B. Administer oxygen using venturi mask
- C. Maintain IV normal saline infusion at prescribed rate of 125 mL/hr
- D. Place the head of the bed in semi-Fowler position
Correct Answer: B
Rationale: Disorientation and restlessness suggest hypoxia. Administering oxygen via a venturi mask delivers precise oxygen concentrations to improve oxygenation, addressing the priority concern. Lorazepam may worsen respiratory depression, IV fluids do not address hypoxia, and semi-Fowler aids breathing but is secondary.
An adult who is being admitted to the medical floor with a bleeding ulcer exhibits all of the following. Which finding suggests that the client may be experiencing alcohol withdrawal symptoms?
- A. BP=90/60
- B. Dizziness
- C. Tremors
- D. Pallor
Correct Answer: C
Rationale: Tremors are a classic sign of alcohol withdrawal, distinguishing it from bleeding ulcer symptoms like hypotension, dizziness, or pallor.
The nurse is caring for assigned clients. The nurse should recognize the client at highest risk for developing a pulmonary embolism is the client who
- A. has pneumonia
- B. has a subdural hematoma
- C. had a cesarean birth 6 hours ago
- D. is receiving hormone replacement therapy
Correct Answer: C
Rationale: Recent cesarean birth increases pulmonary embolism risk due to immobility, surgical trauma, and hypercoagulability postpartum. Pneumonia, subdural hematoma, and hormone therapy carry lower or less immediate risks in this context.
Which of these clients is at greatest risk for the complications associated with osteoporosis?
- A. A 22-year-old woman with anorexia nervosa who is not having menstrual periods
- B. A 65-year-old Asian-American man who is sedentary, has a low calcium intake, and takes corticosteroids for chronic obstructive pulmonary disease
- C. A 70-year-old postmenopausal woman who has limited mobility due to rheumatoid arthritis, for which she takes corticosteroids, and who drinks a bottle of wine by herself each evening
- D. A 70-year-old woman who takes estrogen therapy, was very athletic in her youth playing tennis and golf, and takes anticonvulsant therapy as a result of a head injury suffered in an auto accident three years ago
Correct Answer: C
Rationale: The 70-year-old postmenopausal woman has multiple risk factors: age, immobility, corticosteroid use, and alcohol consumption, maximizing osteoporosis complication risk.