Nokea
The nurse should consider which of the following as a possible cause for the symptoms experienced by the client in Question 28?
- A. iron deficiency
- B. folate deficiency
- C. peptic ulcer
- D. iron overload
Correct Answer: A
Rationale: Due to her symptoms of fatigue, shortness of breath, lightheadedness, her gender, and her fad dieting, the cause is most likely iron deficiency.
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A hospitalized client has just been informed that he has terminal cancer. He says to the nurse, 'There must be some mistake in the diagnosis.' The nurse determines that the client is demonstrating which of the following?
- A. denial
- B. anger
- C. bargaining
- D. acceptance
Correct Answer: A
Rationale: Denial (Kübler-Ross's Stages of Grieving) is the refusal to believe that loss is happening.
Which of the following coping mechanisms protects an individual from anxiety?
- A. denial and fantasy
- B. rationalization and suppression
- C. regression and displacement
- D. reaction formation and projection
Correct Answer: A
Rationale: Denial and fantasy reduce anxiety by avoiding or reimagining reality, serving as protective coping mechanisms, unlike the other options, which may not consistently reduce anxiety.
A person using over-the-counter nasal decongestant drops who reports unrelieved and worsening nasal congestion should be instructed to:
- A. switch to a stronger dose of the medication.
- B. discontinue the medication for a few weeks.
- C. continue taking the same medication, but use it more frequently.
- D. use a combination of medications for better relief.
Correct Answer: B
Rationale: Prolonged use of decongestant drops (3 to 5 days) can lead to rebound congestion, which is relieved by discontinuing the medication for 2 to 3 weeks. Nasal congestion results from dilation of nasal blood vessels due to infection, inflammation, or allergy. With this dilation, there is a transudation of fluid into the tissue spaces, resulting in swelling of the nasal cavity. Nasal decongestants (sympathomimetic amines) stimulate the alpha-adrenergic receptors, producing vascular constriction (vasoconstriction) of the capillaries within the nasal mucosa. The result is shrinking of the nasal mucous membranes and a reduction in fluid secretion (runny nose). Decongestants can make a client jittery, nervous, or restless. These side effects decrease or disappear as the body adjusts to the drug. When nasal decongestants are used for longer than 5 days, instead of the nasal membranes constricting, vasodilation occurs, causing increased stuffy nose and nasal congestion. The nurse should emphasize the importance of limiting the use of nasal sprays and drops. As with any alpha-adrenergic drug (for example, decongestants), blood pressure and blood glucose levels can increase. These drugs are contraindicated and should only be used with extreme caution for clients with hypertension, cardiac disease, hyperthyroidism, and diabetes mellitus.
Ashley and her boyfriend Chris, both 19 years old, are transported to the Emergency Department after being involved in a motorcycle accident. Chris is badly hurt, but Ashley has no apparent injuries, though she appears confused and has trouble focusing on what is going on around her. She complains of dizziness and nausea. Her pulse is rapid, and she is hyperventilating. The nurse should assess Ashley's level of anxiety as:
- A. mild.
- B. moderate.
- C. severe.
- D. panic.
Correct Answer: C
Rationale: The person whose anxiety is assessed as severe is unable to solve problems and has a poor grasp of what's happening in his or her environment. Somatic symptoms such as those described by Ashley are usually present. Vital sign changes are observed. The individual with mild anxiety might report being mildly uncomfortable and might even find performance enhanced. The individual with moderate anxiety grasps less information about the situation, has some difficulty problem-solving, and might have mild changes in vital signs. The individual in panic demonstrates markedly disturbed behavior and might lose touch with reality.
The Token Economy is a type of therapy that focuses on:
- A. play therapy.
- B. behavior modification.
- C. milieu therapy.
- D. associative.
Correct Answer: B
Rationale: Behavior modification gives positive feedback and rewards for appropriate behavior.