Nokea
The psychiatric nurse best demonstrates an understanding of the general health challenges facing a mentally ill client who reports auditory hallucinations when asking:
- A. When did you first start hearing voices?'
- B. What did you have to eat last night for supper?'
- C. May I have your permission to take your blood pressure?'
- D. Do you understand why you need to take your medication?'
Correct Answer: C
Rationale: The correct answer is C because asking for permission to take the client's blood pressure demonstrates respect for their autonomy and acknowledges their physical health needs. It shows an understanding that mental illness can impact physical health and encourages holistic care. Choice A focuses on the onset of hallucinations, but does not address immediate health concerns. Choice B is unrelated to the client's health challenges. Choice D addresses medication compliance but does not directly address the client's current health status. Overall, choice C is the best option as it considers both the client's mental and physical well-being.
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The nurse is monitoring a patient with AIDS. Which manifestation should the nurse expect to observe in this patient?
- A. Diarrhea
- B. Chest pain
- C. Hypertension
- D. Pustular skin lesions
Correct Answer: A
Rationale: The correct answer is A: Diarrhea. Patients with AIDS commonly experience diarrhea due to opportunistic infections or medications. This can lead to dehydration and malnutrition. Choice B is incorrect because chest pain is not a typical manifestation of AIDS. Choice C is incorrect as hypertension is not a common symptom of AIDS. Choice D is incorrect as pustular skin lesions are not typically associated with AIDS. Monitoring for diarrhea is crucial to prevent complications in AIDS patients.
A nurse is called to the home of a neighbor and finds an unconscious person still holding a medication bottle labeled pentobarbital sodium. What is the nurse’s first action?
- A. Test reflexes
- B. Check pupils
- C. Initiate vomiting
- D. Establish a patent airway
Correct Answer: D
Rationale: The correct answer is D: Establish a patent airway. The first action in any emergency situation involving an unconscious person is to ensure their airway is open and clear to facilitate breathing. This is crucial for maintaining oxygenation and preventing potential complications like hypoxia. Testing reflexes (A) and checking pupils (B) are important assessments but not the immediate priority in this situation. Initiating vomiting (C) is contraindicated as it can lead to further complications, especially if the person has ingested a potentially harmful substance.
Patients of Asian Indian origin who use alternative medical treatments are most likely to subscribe to which of the following?
- A. Moxibustion
- B. Reiki
- C. Ayurvedic medicine
- D. Opium
Correct Answer: C
Rationale: Ayurvedic medicine is widely used in Indian culture for holistic healing.
Carol, a nurse in a family medicine outpatient clinic, conducts initial interviews when new families are referred. She has just finished interviewing a mother who has come to the clinic with her three children, ages 5, 7, and 11. The mother says to the oldest child, 'You have been such a help to me, playing with your brothers while I talk to the nurse.' In assessing family interaction, the nurse recognizes this statement as a direct indicator of which of the following?
- A. Family climate
- B. Family members’ expectations
- C. Handling differences
- D. Self-concept reinforcement
Correct Answer: D
Rationale: The correct answer is D: Self-concept reinforcement. The mother's statement to the oldest child acknowledges and reinforces the child's positive behavior of helping with siblings, which can contribute to enhancing the child's self-concept. This type of positive reinforcement can boost the child's self-esteem and self-worth. It also indicates that the mother values and appreciates the child's role in the family dynamic, which can have a positive impact on the child's self-perception and confidence.
A: Family climate - While the mother's statement may reflect a positive family climate, the focus is more on individual behavior and self-concept reinforcement.
B: Family members’ expectations - The statement does not directly relate to expectations but rather acknowledges the child's helpful behavior.
C: Handling differences - The statement does not pertain to resolving conflicts or differences within the family but rather highlights positive behavior.
The theorist associated with scaffolding is
- A. Jean Piaget
- B. Erik Erikson
- C. Lev Vygotsky
- D. John Dewey
Correct Answer: C
Rationale: Vygotsky's scaffolding provides temporary support for learning.