Nokea
A client has been brought into the emergency room for treatment of a suspected drug overdose. The client appears to be highly agitated, fearful, and may be hallucinating.
The nurse should anticipate the client's need for
- A. immediate support from family and friends who accompanied her.
- B. a warm, friendly approach to reduce fears.
- C. a quiet, darkened room to decrease sensory stimulation.
- D. an immediate referral to a social service agency.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) inappropriate at this time because the client is not in contact with reality (2) may agitate the client further (3) correct-sensory stimulation would only increase agitation and could potentially lead to aggressive behavior and injury (4) not the priority at this time
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An adult is admitted in diabetic ketoacidosis. What observation by the nurse is consistent with the diagnosis?
- A. Deep respirations
- B. Foul breath
- C. Constipation
- D. Red rash
Correct Answer: A
Rationale: Deep, rapid (Kussmaul) respirations are a compensatory mechanism in diabetic ketoacidosis to eliminate excess CO2, correcting acidosis.
After 4 electroconvulsive treatments over 2 weeks, a client is very upset and states 'I am so confused. I lose my money. I just can't remember telephone numbers.' The most therapeutic response for the nurse to make is
- A. You were seriously ill and needed the treatments.'
- B. Don't get upset. The confusion will clear up in a day or two.'
- C. It is to be expected since most clients have the same results.'
- D. I can hear your concern and that your confusion is upsetting to you.'
Correct Answer: D
Rationale: Communicating caring and empathy with the acknowledgement of feelings is the initial response. Afterwards, teaching about the expected short-term effects would be discussed.
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
An adult male is admitted with urolithiasis. The nurse expects which orders for this client? Select all that apply.
- A. Push fluids
- B. Strain all urine
- C. Medicate for pain PRN
- D. Clean catch daily
- E. Daily catheterizations
- F. Clear liquid diet
Correct Answer: A,B,C
Rationale: Pushing fluids promotes stone passage, straining urine captures stones for analysis, and pain medication addresses colic in urolithiasis. Clean catch, catheterization, or clear liquids are not standard.
The nurse is caring for a client with a history of bipolar disorder who is receiving valproic acid (Depakote) 500 mg PO bid. Which of the following laboratory results should the nurse report immediately?
- A. Liver enzymes elevated to twice normal.
- B. Sodium 140 mEq/L.
- C. Potassium 4.0 mEq/L.
- D. Hemoglobin 13 g/dL.
Correct Answer: A
Rationale: Elevated liver enzymes suggest hepatotoxicity, a serious valproic acid side effect. Options B, C, and D are normal.