Nokea
The nurse is the leader of a group of mentally retarded adults. The nurse instructs the group members to ignore another client whenever he interrupts others who are speaking. To evaluate the progress of this intervention, the nurse should
- A. measure improvement by counting the number of times the client succeeds.
- B. measure improvement by counting the number of interruptions.
- C. assess the ability of the group to control the client’s interruptions.
- D. count the number of tokens and earned privileges given for interruptions.
Correct Answer: A
Rationale: Counting successful non-interruptions measures the client’s behavioral improvement, the goal of the intervention. Options B, C, and D are less effective: counting interruptions tracks failures, group control is secondary, and tokens are not given for interruptions.
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A young adult client is scheduled for her first debridement of a second-degree burn of the left arm.
It is MOST important for the nurse to take which of the following actions?
- A. Assemble all necessary supplies and medications.
- B. Plan adequate time for the dressing change and provide emotional support.
- C. Prepare the client and family for the pain the client will experience during and after the procedure.
- D. Limit visitation prior to the procedure to reduce stress.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) appropriate, but is not a high priority (2) correct-planning for burn wound treatment should include organizing and planning to spend time not only on the mechanics of the procedure, but on providing the emotional support necessary for the client (3) appropriate, but is not a high priority (4) appropriate, but is not a high priority
The nurse is caring for a client with a history of HIV/AIDS.
- A. Which laboratory finding is most concerning for a client with HIV/AIDS?
- B. CD4 count of 150 cells/mm³.
- C. Viral load of 10,000 copies/mL.
- D. White blood cell count of 5,000/mm³.
- E. Hemoglobin of 12.0 g/dL.
Correct Answer: A
Rationale: A CD4 count of 150 cells/mm³ indicates severe immunosuppression in HIV/AIDS, increasing infection risk and requiring immediate intervention. High viral load is concerning but less urgent, and normal WBC and hemoglobin are unremarkable.
A client has received an IV antibiotic every eight hours for four days.
- A. Which finding would cause the nurse to be concerned about postinfusion phlebitis in a client receiving IV antibiotics?
- B. Tenderness at the IV site.
- C. Increased swelling at the insertion site.
- D. Reddened area or red streaks at the site.
- E. Leaking of fluid around the IV catheter.
Correct Answer: C
Rationale: Postinfusion phlebitis is characterized by inflammation, with reddened areas or streaks along the vein. Tenderness is common, swelling suggests infiltration, and leaking indicates poor catheter placement, but redness is the hallmark of phlebitis.
The nurse is teaching a client with a new diagnosis of gastroesophageal reflux disease (GERD) about omeprazole (Prilosec). Which of the following instructions should the nurse include?
- A. Take the medication at bedtime
- B. Report any diarrhea
- C. Stop the medication if symptoms resolve
- D. Avoid taking with meals
Correct Answer: B
Rationale: Diarrhea may indicate Clostridium difficile infection, a serious omeprazole side effect. Options A, C, and D are incorrect: morning dosing is preferred, stopping the medication risks relapse, and it can be taken with meals.
An 18-year-old client with anorexia nervosa is admitted to the hospital.
In planning to care for the client, the nurse would expect the client to
- A. view her appearance as 'skinny.'
- B. be hypoactive and withdrawn.
- C. want to talk about and plan her meals.
- D. have a close relationship with her mother.
Correct Answer: C
Rationale: Strategy: Determine how each answer choice relates to anorexia. (1) usually view their appearance as fat (2) inaccurate for client with anorexia nervosa (3) correct-display a marked preoccupation with food (4) inaccurate for client with anorexia nervosa