Nokea
The nurse understands that a priority goal of involuntary hospitalization of the severely mentally ill client is
- A. Re-orientation to reality
- B. Elimination of symptoms
- C. Protection from harm to self or others
- D. Return to independent functioning
Correct Answer: C
Rationale: Protection from harm to self or others. Involuntary hospitalization is required for individuals who are dangerous to themselves or others.
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An adult woman who has multiple sclerosis (MS) asks the nurse why she developed multiple sclerosis. What information should the nurse include when responding?
- A. MS usually follows a streptococcal infection.
- B. MS is an autoimmune condition.
- C. MS occurs more often among persons who have had chickenpox.
- D. MS may be related to mosquito bites.
Correct Answer: B
Rationale: Multiple sclerosis is an autoimmune disorder where the immune system attacks myelin in the central nervous system, unlike infections or mosquito bites.
The clinic nurse is preparing to administer an allergy immunotherapy injection to a client recently initiated on the therapy. Which statement by the client indicates a need for further teaching?
- A. I can leave right after the shot as I didn't have a reaction last time.'
- B. I will be back in a week for my next allergy shot.'
- C. I will let the doctor know if I get any itchy hives tonight.'
- D. It is okay if I have some redness at the injection site tonight.'
Correct Answer: A
Rationale: Leaving immediately after an allergy shot is unsafe due to the risk of delayed anaphylaxis, requiring a 20–30 minute observation period. Weekly shots , reporting hives , and mild redness are appropriate.
The drug of choice for managing status epilepticus is:
- A. Carbamazepine (Tegretol)
- B. Diazepam (Valium)
- C. Clonazepam (Klonopin)
- D. Valproic acid (Depakene)
Correct Answer: B
Rationale: Diazepam is the first-line treatment for status epilepticus due to its rapid onset in stopping seizures.
The clinic nurse is reinforcing teaching to a client who has been prescribed transdermal scopolamine to prevent motion sickness during an upcoming vacation on a cruise ship. Which of the following statements made by the nurse are appropriate? Select all that apply.
- A. Apply the patch when the ship starts moving and not before.'
- B. Dispose of the patch out of reach of children and pets.'
- C. Ensure that the old patch is removed before applying a new one.'
- D. Place the patch on a hairless, clean, dry area behind the ear.'
- E. Wash your hands with soap and water after handling the patch.'
Correct Answer: B,C,D,E
Rationale: Appropriate scopolamine instructions include safe disposal , removing old patches , correct placement , and hand washing . Applying the patch only when moving is incorrect, as it should be applied hours before travel.
The doctor has ordered the insertion of an NG tube to determine the extent of gastric bleeding in a client with a gastric ulcer. To facilitate the insertion of the NG tube, the nurse should:
- A. Place the NG tube in warm water prior to insertion.
- B. Place the client in a supine position.
- C. Ask the client to swallow as the tube is advanced.
- D. Ask the client to hyper-extend his neck as the nurse begins to insert the tube.
Correct Answer: C
Rationale: Asking the client to swallow helps guide the NG tube into the esophagus and stomach, facilitating insertion.