The nurse is talking with a client with obsessive-compulsive personality disorder who is scheduled for a colonoscopy. Due to a computer malfunction, the procedure is being postponed by 2 hours. Which of the following responses by the client would be consistent with obsessive-compulsive personality disorder?
- A. How dare they change my appointment time. I insist that the procedure be done at the scheduled time
- B. I do not understand why they would do this. It seems like they just want to make things difficult for me
- C. That is not a problem. I can come in whenever it is convenient for everyone
- D. This is unacceptable. I had my whole day planned out and I cannot change my plan
Correct Answer: D
Rationale: Obsessive-compulsive personality disorder involves rigidity and need for control, so resistance to schedule changes is typical. The other responses reflect anger, paranoia, or flexibility, less characteristic of the disorder.
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A home health nurse is caring for a client with a pressure sore that is red, with serous drainage, is 2 inches in diameter with loss of subcutaneous tissue. The appropriate dressing for this wound is
- A. Transparent film dressing
- B. Wet dressing with debridement granules
- C. Wet to dry with hydrogen peroxide
- D. Moist saline dressing
Correct Answer: D
Rationale: Moist saline dressing. A stage III pressure ulcer with granulation tissue requires a moist environment to promote healing.
A paraplegic client is in the hospital to be treated for an electrolyte imbalance. Which level of care is the client currently receiving?
- A. primary prevention
- B. secondary prevention
- C. tertiary prevention
- D. health promotion
Correct Answer: B
Rationale: This client is receiving secondary prevention. The current focus of health care is on preventive care. Leavell and Clark (1965) described the three levels of preventive care as primary, secondary, and tertiary. Secondary preventive care focuses on early detection of disease, prompt intervention, and health maintenance for clients experiencing health problems.
The health care provider prescribes a multivitamin regimen that includes thiamine for a client with a history of chronic alcohol abuse. The nurse is aware that thiamine is given to this client population for which purpose?
- A. To lower the blood alcohol level
- B. To prevent gross tremors
- C. To prevent Wernicke encephalopathy
- D. To treat seizures related to acute alcohol withdrawal
Correct Answer: C
Rationale: Thiamine prevents Wernicke encephalopathy, a neurological disorder from thiamine deficiency common in chronic alcoholism. It does not lower alcohol levels, prevent tremors, or treat seizures directly.
The nurse is caring for a client with bipolar I disorder who is experiencing an acute manic episode. Which of the following meals would be appropriate to offer the client?
- A. Baked sweet potato, kale, wheat roll, water
- B. Chicken nuggets, almonds, apple slices, milk
- C. Vegetable soup, fresh salad, dinner roll, iced tea
- D. Spaghetti with meatballs, fruit salad, sliced bread, coffee
Correct Answer: A
Rationale: A simple meal like sweet potato, kale, wheat roll, and water minimizes stimulation and is easy to eat during mania. Other meals are more complex or contain caffeine (coffee, tea), which can exacerbate symptoms.
The nurse is performing a sterile dressing change for a client when a second client begins yelling for pain medication. Which of the following actions should the nurse take?
- A. Ask unlicensed assistive personnel (UAP) to take the second client’s vital signs and report back immediately
- B. Direct UAP to ask the second client to rate the pain on a 0-10 scale and report back immediately
- C. Inform UAP to tell the second client that the nurse will be there soon and complete the sterile dressing change
- D. Interrupt the dressing change to medicate the second client
Correct Answer: C
Rationale: Completing the sterile dressing change maintains sterility and infection control, while informing the UAP to reassure the second client ensures their needs are addressed promptly without compromising the first client’s care.
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