Nokea
The nurse is working on discharge plans with a client who is diagnosed with intermittent explosive disorder, characterized by sudden angry outbursts. The nurse determines that the client is ready for discharge when he makes which of the following comments?
- A. I'm just not going to let myself get angry anymore.'
- B. Spilling doesn't help, but I like being with my buddies at the bar.'
- C. I'll be taking valproic acid (Depakote) and propranolol (Inderal) to help stay in control.'
- D. It would help if my mom would stop getting on my case all the time.'
Correct Answer: C
Rationale: Understanding the role of medications (valproic acid and propranolol) in controlling outbursts indicates readiness for discharge in managing intermittent explosive disorder.
You may also like to solve these questions
The nurse is observing an unlicensed assistive personnel (UAP) care for an older client who had surgery (insertion of a prosthesis) following a hip fracture 4 days ago. To prevent client injury, the nurse should intervene in the care when which action is performed by the UAP?
- A. Elevates the head of bed 30 degrees
- B. Assists the client in inserting dentures
- C. Obtains a bedside commode to keep in the room
- D. Places pillows between the legs when turning the client
Correct Answer: C
Rationale: After hip surgery when a prosthesis has been inserted, a client should not flex the body more than 90 degrees relative to the chair; sitting on a commode would mean a low seat. The toilet seat should be raised, so a special adapted commode should be placed in the room. The head of the bed can be raised slightly for comfort. Assisting the client in inserting dentures is within the duties of a UAP. The legs should be kept abducted, so using pillows between the legs when turning is required.
The nurse observes an 18-month-old who has been admitted with a respiratory tract infection (see figure). The nurse should first:
- A. Position the child supine
- B. Call the rapid response team
- C. Offer the child a carbonated drink
- D. Place the child in a croup tent
Correct Answer: B
Rationale: An 18-month-old with a respiratory tract infection may be in respiratory distress, requiring immediate action by calling the rapid response team. Positioning supine or offering a drink could worsen breathing, and a croup tent is specific to croup, not all infections.
You measure your 5 year old client's vital signs as: • Respiratory rate: 32 breaths per minute • Pulse: 100 beats per minute • Blood pressure: 85/55. The mother asks you if these vital signs are normal. You should respond to this mother's question by stating:
- A. The respiratory rate is a little too fast but the other vital signs are normal.'
- B. The pulse rate is a little too fast but the other vital signs are normal.'
- C. The blood pressure is a little low but the other vital signs are normal.'
- D. All of these vital signs are normal for a child that is 2 years of age.'
Correct Answer: A
Rationale: For a 5-year-old, normal ranges are approximately: respiratory rate 20-25 breaths/min, pulse 70-115 beats/min, blood pressure ~90-110/55-65 mmHg. The respiratory rate (32) is slightly high, while the pulse and blood pressure are within normal limits.
Select the sound that is heard with percussion with its description.
- A. Tympany: A hollow sound
- B. Dullness: A thud like sound
- C. Dullness: A hollow sound
- D. Resonance: A booming sound
Correct Answer: A,B,D
Rationale: Tympany is a hollow sound (e.g., over air-filled structures like the stomach), dullness is a thud-like sound (e.g., over solid organs like the liver), and resonance is a booming sound (e.g., over lung tissue). Option C is incorrect because dullness is not a hollow sound.
The nurse is caring for a client who has been diagnosed with pernicious anemia. Which of the following statements by the client indicates an understanding of the treatment of pernicious anemia?
- A. I will need to increase my dietary intake of foods that are high in vitamin B12.'
- B. I will receive my first injection of vitamin B12 tomorrow, and I will return for a follow-up injection in 1 month.'
- C. I understand that the oral form of vitamin B12 is preferred because it is safer and less expensive than the injection form.'
- D. I will need to take vitamin B12 replacements for the rest of my life.'
Correct Answer: D
Rationale: Pernicious anemia requires lifelong vitamin B12 injections due to intrinsic factor deficiency, preventing absorption of dietary or oral B12.