Nokea
What are these sensory phenomena called when a client hears voices or sees images that do not objectively exist?
- A. Mania
- B. Delusions
- C. Seasonal affective disorder
- D. Hallucinations
Correct Answer: D
Rationale: Hallucinations involve perceiving things that are not present, such as hearing voices or seeing images.
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Joan is diagnosed with a ruptured aneurysm. She wonders why this was not picked up in her annual physical. You respond by saying
- A. The physician must have misread the x-ray.
- B. The aneurysm must have developed since the physical.
- C. Aneurysms are often asymptomatic.
- D. Do not be too concerned because this happens all the time.
Correct Answer: C
Rationale: Aneurysms can develop silently without noticeable symptoms.
Which nursing interventions should not be delegated to unlicensed assistive personnel (UAP) but should be performed by the RN (select all that apply)?
- A. Administering patient medications
- B. Ambulating stable patients
- C. Performing patient assessment
- D. Evaluating the effectiveness of patient care
Correct Answer: A
Rationale: Medication administration, assessment, evaluation, and teaching require the RN's specialized knowledge and accountability.
Justin Mack, 20, was critically injured in a motorcycle accident and is not expected to survive. His parents, after arriving at the hospital from several hundred miles away, are asked to give important information about Justin, including:
- A. his childhood immunization schedule.
- B. whether Justin wanted to be an organ donor.
- C. the number of siblings Justin had.
- D. previous hospitalizations and surgeries.
Correct Answer: B
Rationale: Finding out about his childhood immunizations is of minor importance, given the prognosis. Getting information about whether Justin expressed the desire to donate his organs would be important at this time. Asking about the number of siblings might be a conversation opener, but is not of high importance to Justin's care. Previous hospitalizations and surgeries are irrelevant unless the organ donation is being considered, and this would then be important to learn.
What is the main drawback of the botulism antitoxin that the nurse should be aware of?
- A. It causes 9% hypersensitivity.
- B. It requires monthly booster dosages.
- C. It is not available from the CDC.
- D. It is not available as a pre-exposure vaccine.
Correct Answer: D
Rationale: The correct answer is D because botulism antitoxin is not available as a preventive vaccine.
Before giving a beta-adrenergic blocker glaucoma agent, you would notify the physician if the client discloses a history of what condition?
- A. Hypertension
- B. Tachycardia
- C. Rheumatoid arthritis
- D. Bradycardia
Correct Answer: D
Rationale: Beta-adrenergic blockers can exacerbate bradycardia, so the physician should be notified before administration.