Nokea
A client with an obsessive-compulsive disorder manifested by the compulsion of handwashing.
The nurse knows that which of the following BEST describes the client's need for the repetitive acts of handwashing?
- A. Handwashing represents an attempt to manipulate the environment to make it more comfortable.
- B. Handwashing externalizes the anxiety from a source within the body to an acceptable substitute outside the body.
- C. Handwashing assists the client to avoid undesirable thoughts and maintain some control over guilt and anxiety.
- D. Handwashing helps to maintain the client in an active state to resist the effects of depression.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) not a manipulation on the client's part (2) not an accurate statement regarding the compulsive behavior of this client (3) correct-compulsive behavior is an unconscious attempt to control and/or relieve the tension and anxiety the client is experiencing (4) client is not subject to depression but to high levels of anxiety
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The nurse must know that the most accurate oxygen delivery system available is
- A. the Venturi mask
- B. nasal cannula
- C. partial non-rebreather mask
- D. simple face mask
Correct Answer: A
Rationale: The most accurate way to deliver oxygen to the client is through a Venturi system such as the Venti Mask. The Venti Mask is a high flow device that entrains room air into a reservoir device on the mask and mixes the room air with 100% oxygen. The size of the opening to the reservoir determines the concentration of oxygen. The client's respiratory rate and respiratory pattern do not affect the concentration of oxygen delivered. The maximum amount of oxygen that can be delivered by this system is 53%.
The nurse is caring for a client with a history of heart failure who is receiving spironolactone (Aldactone) 25 mg PO daily. Which of the following laboratory results should the nurse report immediately?
- A. Potassium 5.8 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hyperkalemia (5.8 mEq/L) is a serious spironolactone side effect, risking arrhythmias. Options B, C, and D are normal.
A client has just been admitted with portal hypertension. Which nursing diagnosis would be a priority in planning care?
- A. Altered nutrition: less than body requirements
- B. Potential complication hemorrhage
- C. Ineffective individual coping
- D. Fluid volume excess
Correct Answer: B
Rationale: Potential complication hemorrhage. Esophageal varices are dilated and tortuous vessels of the esophagus that are at high risk for rupture if portal circulation pressures rise.
A 10-year-old child is admitted to the hospital with injuries. Which finding most suggests that additional assessment for child abuse is indicated?
- A. The child asks to have friends visit.
- B. The child asks to have a teacher bring in homework.
- C. The child's parents state that they need to spend some time with the child's siblings.
- D. The child's parents will not leave the child alone while in the hospital.
Correct Answer: D
Rationale: Constant parental presence may indicate control or fear of the child disclosing abuse, warranting further abuse assessment.
The nurse is caring for a client who is receiving IV fluids at 150 mL/hour. Which of the following findings indicates fluid overload?
- A. Blood pressure of 120/80 mmHg.
- B. Heart rate of 80 bpm.
- C. Crackles in the lung bases.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Crackles in the lung bases suggest pulmonary edema from fluid overload. Options A, B, and D are normal findings.