Nokea
The nurse monitors a client diagnosed with silicosis for emotional reactions related to the chronic respiratory disease. Which emotional reaction, when expressed by the client, indicates a need for immediate intervention?
- A. Anxiety
- B. Depression
- C. Suicidal ideation
- D. Ineffective coping
Correct Answer: C
Rationale: Suicidal ideation is not a normal emotional reaction with this condition. If it is expressed, it warrants immediate intervention. Common emotional reactions to a disease such as massive pulmonary fibrosis may be the same as for chronic airflow limitation and include anxiety, ineffective coping, and depression.
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To protect a client who has received tissue plasminogen activator (t-PA, or Activase) therapy, the nurse should:
- A. Use the radial artery to obtain blood gas samples.
- B. Maintain arterial pressure for 10 seconds.
- C. Administer I.M. injections.
- D. Encourage physical activity.
Correct Answer: B
Rationale: Maintaining pressure on arterial puncture sites for 10 seconds minimizes bleeding risk, critical after t-PA due to its thrombolytic effects.
Identify this cardiac rhythm strip. Fill in the blank. A. Idioventricular Rhythm B. Bundle Branch Block C. Sinus bradycardia D. Atrial Flutter
- B. Idioventricular Rhythm
- C. Bundle Branch Block
- D. Sinus bradycardia
- E. Atrial Flutter
Correct Answer: C
Rationale: Sinus bradycardia is characterized by a regular rhythm with a rate below 60 beats per minute, assuming the strip shows this pattern.
The nurse is assessing a client with a suspected bowel obstruction. Which of the following findings is most indicative of this condition?
- A. Abdominal distension.
- B. Decreased bowel sounds.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A,B
Rationale: Abdominal distension and decreased bowel sounds are hallmark signs of bowel obstruction due to blocked intestinal passage.
The nurse reviewing the electrocardiogram (ECG) rhythm strip of a client with a history of a myocardial infarction (MI) notes that the PR intervals are 0.16 seconds. The nurse should arrive at which interpretation of this assessment data?
- A. A normal finding
- B. An abnormal finding
- C. An impending reinfarction
- D. First-degree atrioventricular (AV) block
Correct Answer: A
Rationale: The PR interval represents the time it takes for the cardiac impulse to spread from the atria to the ventricles. The PR interval range is 0.12 to 0.2 seconds. Therefore, the finding is normal. The remaining options all indicate an abnormal finding, so they are not appropriate responses.
A client with iron deficiency anemia is taking iron supplements. The nurse emphasizes to the client that the drug will have increased absorption if taken with:
- A. Milk
- B. Orange juice
- C. Food
- D. Beta-carotene
Correct Answer: B
Rationale: Iron absorption is enhanced by vitamin C, found in orange juice, while milk and food can decrease absorption. Beta-carotene does not significantly affect iron absorption.