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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What are the factors that interfere with a client’s learning capacity? How can receptiveness to learning be increased?
- A. Stress,fatigue and lack of interest; create a supportive environment.
- B. Lack of resources; provide more materials.
- C. Cultural differences; adapt teaching methods.
- D. None of the above.
Correct Answer: A
Rationale: Factors like stress and fatigue hinder learning. Creating a supportive, stress-free environment enhances receptiveness.
The physician has written orders for the client with Excess Fluid Volume. The client's morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which order takes priority at this time?
- A. Weigh client every morning
- B. Maintain accurate intake and output
- C. Restrict fluid to 1500 mL per day
- D. Administer furosemide (Lasix) 40 mg IV push
Correct Answer: D
Rationale: The correct answer is D: Administer furosemide (Lasix) 40 mg IV push. This is the priority because the client is showing signs of fluid volume excess, such as weight gain, pitting edema, and crackles, which indicate fluid overload in the lungs. Furosemide is a loop diuretic that helps to remove excess fluid from the body quickly, making it crucial in managing excess fluid volume in this situation. Weighing the client daily (A) is important but not as urgent as addressing the immediate symptoms of fluid overload. Maintaining accurate intake and output (B) is essential for overall fluid balance but does not address the immediate excess fluid volume. Fluid restriction (C) may be needed in the long term, but immediate intervention with furosemide is necessary to prevent worsening of symptoms and potential complications.
The following data are organized according to Gordon’s functional health patterns.
- A. 78-year-old woman
- B. Married, three grown children who all live out of town
- C. Cares for invalid husband in home with help of daily homemaker
- D. Vision corrected with glasses; hearing normal
Correct Answer: A
Rationale: N/A
The patient experiences sudden pain in his right calf while sitting at home. He is diagnosed with deep vein thrombosis (DVT). The first intervention is to
- A. Apply ice packs to the affected area every 4 to 6 hours.
- B. Increase dietary intake of foods rich in vitamin K.
- C. Monitor platelet counts daily.
- D. Use intermittent warm soaks of the affected area.
Correct Answer: C
Rationale: Monitoring platelets is crucial when anticoagulants are administered.
To prepare a patient on the unit for a bronchoscopic procedure, the medical-surgical nurse administers an IV sedative. The nurse then instructs the licensed practical nurse to
- A. educate the patient about the procedure.
- B. give the patient small sips of water only.
- C. measure the patient's blood pressure and heart rate.
- D. take the patient to the bathroom one more time.
Correct Answer: D
Rationale: Emptying the bladder before the procedure is important for comfort and safety.