Nokea
A client with an obsessive-compulsive ritual.
The nurse recognizes that the client with an obsessive-compulsive ritual is attempting to
- A. control other people.
- B. increase self-esteem.
- C. avoid severe levels of anxiety.
- D. express and manage anxiety.
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) inaccurate (2) inaccurate (3) correct-obsessive-compulsive rituals are an attempt to avoid or alleviate increasing levels of anxiety; client is not trying to increase his self-esteem or control others with the ritualistic behaviors; these behaviors do not have a significant impact on others; client does not want to repeat the act but feels compelled to do so (4) ritual is not a method of expressing anxiety, but a strategy to avoid it
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The nurse is caring for a client with a history of eating disorders.
- A. Which client statement indicates a need for further teaching about anorexia nervosa?
- B. I need to gain weight slowly to stay healthy.'
- C. I can stop dieting once I reach my goal weight.'
- D. I should eat balanced meals regularly.'
- E. I need support to change my eating habits.'
Correct Answer: B
Rationale: Stating that dieting can stop at a goal weight suggests a misunderstanding, as anorexia requires ongoing nutritional and psychological management. Slow weight gain, balanced meals, and support are correct.
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings should the nurse report immediately?
- A. Mild redness at the IV site.
- B. Temperature of 100.8°F (38.2°C).
- C. Urine output of 50 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests worsening infection, requiring immediate reporting. Options A, C, and D are less urgent or normal.
A client recently diagnosed with bipolar disorder expresses concern over taking Eskalith (lithium carbonate) because 'a lot of people have problems getting too much of it.' The nurse should explain that lithium toxicity typically occurs when the client has an insufficient intake of:
- A. Carbohydrates for energy
- B. Protein for maintenance of cell integrity
- C. Potassium for muscle contractility
- D. Sodium and fluids for renal excretion
Correct Answer: D
Rationale: Lithium toxicity occurs with insufficient sodium and fluids, as low sodium increases lithium reabsorption in kidneys, and fluids aid excretion. Other nutrients are less directly related.
A client is being discharged following insertion of a permanent set pacemaker. A client with a permanent set pacemaker should be taught:
- A. To keep a loose dressing over the insertion site at all times
- B. That the pacemaker will function continuously at a set rate
- C. That increases in activity will require adjustments in the pacemaker setting
- D. That he will have to modify his lifestyle to allow for afternoon rest periods
Correct Answer: C
Rationale: Modern pacemakers adjust their rate based on activity (rate-responsive pacing), so the client should understand that increased activity may require pacemaker adjustments.
A 52-year-old woman complains of chronic constipation.
The nurse in the health care clinic should advise the woman to
- A. reduce her intake of highly seasoned foods and fats.
- B. drink 1,000 cc of fluids daily.
- C. increase her intake of cereals, fresh fruits, and vegetables.
- D. ask her physician to prescribe Dulcolax 5 mg enteric-coated tablets daily.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unnecessary, no effect on constipation (2) normal intake 1,500-2,000, reduced intake causes constipation (3) correct-bulk-forming foods help with constipation (4) passing the buck, laxatives are a last resort