Nokea
The nursing intervention that best describes treatment to deal with the behaviors of clients with personality disorders include
- A. Pointing out inconsistencies in speech patterns to correct thought disorders
- B. Accepting client and the client's behavior unconditionally
- C. Encouraging dependency in order to develop ego controls
- D. Consistent limit-setting enforced 24 hours per day
Correct Answer: D
Rationale: Consistent limit-setting enforced 24 hours per day. This helps restructure maladaptive behaviors in personality disorders.
You may also like to solve these questions
A client recently diagnosed with insulin-dependent diabetes mellitus (IDDM). As part of the treatment plan, the client receives Humulin N 32 units and Humulin R 8 units each morning.
Which of the following actions, if performed by the client while preparing the morning insulin injection, would require an intervention by the nurse?
- A. After the client draws up 8 units of Humulin R, she adds Humulin N to the syringe for a total of 40 units.
- B. The client draws up 32 units of the clear insulin followed by 8 units of cloudy insulin for a total of 40 units.
- C. Initially, the client injects air into the Humulin N vial without drawing up any insulin.
- D. The client injects air into each bottle of insulin equal to the amount of insulin to be withdrawn.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) clear insulin always drawn up first (2) correct-Humulin R is clear and drawn up first, only 8 units are ordered, Humulin N is cloudy (3) allows you to withdraw medication later (4) allows you to withdraw medication later
An arthritic client must be able to perform tasks to manage at home alone following discharge from the hospital.
The nurse knows that to manage at home alone following discharge from the hospital, an arthritic client must be able to perform which of the following tasks?
- A. Climb up and down stairs.
- B. Lace and tie his/her shoes.
- C. Comb his/her hair and brush his/her teeth.
- D. Walk without assistance.
Correct Answer: C
Rationale: Strategy: Think about the significance of each answer choice and how it relates to arthritis. (1) stairs can be eliminated in the client's environment (2) is a modifiable problem with the use of slip-on shoes (3) correct-is part of basic hygiene and grooming that must be done daily to maintain overall health (4) is not necessary for independence; walker or wheelchair may be used
A 12-year-old girl whose tracheostomy tube inserted 2 days ago has been accidentally dislodged.
The nurse should
- A. immediately replace the tracheostomy tube.
- B. suction the patient's airway using sterile technique.
- C. provide oxygen at 8 liters per minute per mask over the stoma.
- D. check for bilateral breath sounds immediately.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of the implementations. Remember ABCs. (1) correct-implementation, will secure the airway (2) implementation, will not provide for open airway (3) implementation, will not help with open airway (4) assessment, should be done after tracheostomy tube is replaced
A client has severe second- and third-degree burns over 75% of his body.
The nurse would be MOST concerned if which of the following was observed?
- A. Epigastric pain.
- B. Restlessness.
- C. Tachypnea.
- D. Lethargy.
Correct Answer: C
Rationale: Strategy: Determine how each answer relates to burns. (1) insignificant for burn client (2) may be due to pain (3) correct-body responds to early hypovolemic shock by adrenergic stimulation; vasoconstriction compensates for the loss of fluid, resulting in cool clammy skin, tachycardia, tachypnea, and pale color (4) may be due to pain
The nurse is caring for a client with a history of heart failure who is receiving digoxin 0.125 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Fatigue and weakness.
- B. Nausea and loss of appetite.
- C. Occasional palpitations.
- D. Mild ankle edema.
Correct Answer: B
Rationale: Nausea and loss of appetite suggest digoxin toxicity, a medical emergency. Options A, C, and D are less specific or expected in heart failure.