Nokea
The serial sevens test is often used to determine delirium and dementia. This test aids in assessing which of the following?
- A. Abstract thinking
- B. Ability to focus and concentrate thoughts
- C. Judgment
- D. Memory
Correct Answer: B
Rationale: This answer is incorrect. The test measures the abilities to concentrate and calculate. The use of proverbs is the most common way to test abstraction. This answer is correct. The serial sevens test is a common test of calculation ability. It is difficult for the demented or delirious client to perform. This answer is incorrect. The test for judgment should predict whether the individual will behave in a socially accepted manner. This answer is incorrect. In testing memory, the nurse would attempt to get the client either to recall recent events or to think about past events.
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A 22-year-old client presents with a diagnosis of antisocial personality disorder and a history of using drugs, writing numerous checks with insufficient funds, and stealing. He appears charming and intelligent, and the other clients are impressed and want to be liked by him. The greatest problem that may arise from this situation is that:
- A. He will manipulate the other clients for his own benefit
- B. He will cause the other clients to become psychotic
- C. He will become delusional and hallucinate as a result of the excess attention given to him by peers
- D. He may exhibit self-mutilative behavior
Correct Answer: A
Rationale: This answer is correct. Persons with antisocial personality disorder typically are very manipulative. This answer is incorrect. The client's behavior cannot cause another person to become psychotic. This answer is incorrect. Psychosis is not a symptom of antisocial personality. One of the criteria for diagnosis of this disorder is that no psychosis be present. In addition, the client would love the attention. This answer is incorrect. Self-mutilative behavior is characteristic of the borderline personality disorder.
The nurse is caring for a client with a history of a tracheostomy. Which intervention is most important when suctioning the tracheostomy?
- A. Using sterile technique
- B. Applying suction for 20 seconds
- C. Instilling saline before suctioning
- D. Using a large-diameter catheter
Correct Answer: A
Rationale: Sterile technique during tracheostomy suctioning prevents infection, a critical concern. Suctioning should last 10-15 seconds, saline is optional, and catheter size should be appropriate.
A client is admitted to the hospital with diabetic ketoacidosis. The emergency room nurse should anticipate the administration of:
- A. Humulin N
- B. Humulin R
- C. Humulin U
- D. Humulin L
Correct Answer: B
Rationale: Regular insulin is rapid acting and indicated in an emergency situation.
A client with a history of chronic migraines is admitted with complaints of headache. The nurse should give priority to:
- A. Administering analgesics
- B. Monitoring blood pressure
- C. Providing a quiet environment
- D. Administering oxygen
Correct Answer: C
Rationale: A quiet environment reduces sensory stimuli, which can exacerbate migraines, making it a priority to promote comfort.
While the nurse is taking a male client's blood pressure, he makes flirtatious remarks to her. The nurse will handle this effectively if she:
- A. Politely tells the client, 'Keep your hands off'
- B. Ignores the remarks and hopes he will not try it again
- C. Confronts the remarks but attempts not to reject the client
- D. Leaves the room in order to compose herself
Correct Answer: C
Rationale: By confronting the remarks, she can recognize that his feelings of attraction may be normal but are not appropriate within the context of their nurse-client relationship.