Nokea
The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? (Round to the nearest tenth.)
- A. 0.2 mL
- B. 0.8 mL
- C. 1.25 mL
- D. 2.0 mL
Correct Answer: B
Rationale: To calculate the volume to administer, use the formula: (Volume to administer = (Ordered Dose × Volume on hand) / Dose on hand). In this case, it would be (4 mg × 1 mL) / 5 mg = 0.8 mL. Therefore, the nurse should administer 0.8 mL of diazepam. Choice A (0.2 mL) is incorrect because it miscalculates the dosage. Choice C (1.25 mL) and Choice D (2.0 mL) are incorrect as they do not align with the correct calculation based on the ordered dose and available concentration. The correct answer, 0.8 mL, is derived from accurate dosage calculation and aligns with the formula for IV medication administration, ensuring the safe and effective delivery of the medication to the client.
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A 16-year-old client with Crohn's disease is hospitalized. Which statement by the client would alert the nurse to a potential developmental problem?
- A. I'd like my hair washed before my friends get here.
- B. Is it okay if I have a couple of friends in to visit me this evening?
- C. Please tell my friends not to visit, since I'll see them back at school next week.
- D. When my friends get here, I would like to play some computer games with them.
Correct Answer: C
Rationale: Adolescents who withdraw from peers into isolation struggle with developing identity, so option 3 should cause the nurse to be concerned. It is appropriate for the client to ask for hygiene measures to be attended to before the peer group arrives. Option 2 indicates that the client is eager for companionship. Adolescents often develop special interests within their groups that may help them maximize certain skills, such as with computers.
A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, 'I want to go outside now and smoke. It takes forever to get anything done here!' Which intervention is best for the nurse to implement?
- A. Encourage the client to use a nicotine patch.
- B. Reassure the client that it is almost time for another break.
- C. Have the client leave the unit with another staff member.
- D. Review the schedule of outdoor breaks with the client.
Correct Answer: D
Rationale: The best nursing action is to review the schedule of outdoor breaks and provide concrete information about the schedule. Suggesting a nicotine patch (Option A) is not suitable as the client wants to smoke. Reassuring the client about another break (Option B) does not address the client's frustration and does not promote effective communication. Having the client leave the unit with another staff member (Option C) is not appropriate as it goes against unit rules and does not address the client's concerns. Therefore, the most appropriate intervention is to review the schedule of outdoor breaks with the client to provide clarity and address the client's frustration effectively.
A mother brings her previously continent 6-year-old son to the pediatric clinic because he has resumed bedwetting. The nurse assesses the home environment and discovers that there is a new baby at home. Which explanation by the nurse best describes for the mother the defense mechanism the son is using?
- A. Regression
- B. Repression
- C. Identification
- D. Rationalization
Correct Answer: A
Rationale: The defense mechanism of regression is characterized by returning to an earlier form of expressing an impulse. Option 2 is characterized by blocking a wish or desire from conscious expression. Option 3 occurs when a person models behavior after someone else. Option 4 occurs when a person unconsciously falsifies an experience by giving a 'rational' explanation.
A female client with the diagnosis of mania emerges from her room topless while making sexual remarks and lewd gestures toward the staff and her peers. Which intervention should the nurse implement first?
- A. Quietly approach the client and escort her to her room to get dressed.
- B. Confront the client on the inappropriateness of her behavior and offer her a time out.
- C. Ask the other clients to ignore her behavior; eventually she will return to her own room.
- D. Approach the client in the hallway and insist that she go to her own room immediately.
Correct Answer: A
Rationale: A person who is experiencing mania lacks insight and judgment, has poor impulse control, and is highly excitable. The nurse must take control without creating increased stress or anxiety for the client. Insisting that the client go to her room may cause the nurse to be met with a great deal of resistance. Confronting the client and offering her a consequence of time out may be meaningless to her. Asking other clients to ignore her is inappropriate. A quiet but firm approach while distracting the client (walking her to her room and helping her to get dressed) achieves the goal of having the client dressed appropriately and preserving her psychosocial integrity.
A client scheduled for pulmonary angiography is fearful about the procedure and asks the nurse if the procedure involves significant pain and radiation exposure. Which therapeutic response should the nurse make to the client to provide reassurance?
- A. The procedure is somewhat painful, but there is minimal exposure to radiation.'
- B. Discomfort may occur with needle insertion, and there is minimal exposure to radiation.'
- C. There is very mild pain throughout the procedure, and the exposure to radiation is negligible.'
- D. There is usually no pain, although a moderate amount of radiation must be used to get accurate results.'
Correct Answer: B
Rationale: Pulmonary angiography involves minimal exposure to radiation. The procedure is painless, although the client may feel discomfort with insertion of the needle for the catheter that is used for dye injection. This information supports the fact that the other options are incorrect.