Nokea
What behavioral clues will you watch for to identify an increased risk for suicide?
- A. Deep breathing exercises
- B. Avoid social interactions
- C. Ignore stressors
- D. Increase workload
Correct Answer: D
Rationale: The correct answer is D because it is the most appropriate response based on physiological and medical principles.
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While on a hiking trip, Mr. Jones states that a branch of a tree struck his eye. Part of the branch remains lodged in the eye, and the eyelid is bleeding. Appropriate emergency treatment would include
- A. covering the eye with a protective shield
- B. encouraging Mr. Jones to hold his eye closed tightly
- C. applying a pressure dressing to the eye
- D. removing the foreign body and applying a sterile dressing
Correct Answer: A
Rationale: Covering the eye with a protective shield prevents further injury while awaiting professional medical evaluation and removal of the foreign object.
A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active, and has no known risk factors for PE. What action by the nurse is most appropriate?
- A. Encourage the client to walk for 5 minutes each hour.
- B. Refer the client for smoking cessation classes.
- C. Teach the client about factor V Leiden testing.
- D. Explain to the client that sometimes no cause for the disease is found.
Correct Answer: C
Rationale: The correct answer is C because teaching the client about factor V Leiden testing is important in this scenario. Factor V Leiden is a genetic mutation that increases the risk of blood clot formation, including pulmonary embolism. Since the client has no known risk factors for PE, testing for this specific genetic mutation can help identify an underlying cause. Encouraging walking (choice A) is generally beneficial but may not address the root cause. Referring for smoking cessation (choice B) is not relevant in this case. Explaining that sometimes no cause is found (choice D) is not proactive and may lead to missed opportunities for prevention.
Felicia's family is concerned because Felicia states that she is hearing voices. This is a sign of
- A. Bipolar disorder.
- B. Schizophrenia.
- C. Panic disorder.
- D. Bulimia nervosa.
Correct Answer: B
Rationale: Auditory hallucinations are a hallmark symptom of schizophrenia.
Which of the following is a sign of presbyopia?
- A. Difficulty seeing distant objects
- B. Difficulty seeing close objects
- C. Double vision
- D. Color blindness
Correct Answer: B
Rationale: Presbyopia is the gradual loss of near focusing ability, making it difficult to see close objects.
A 54-year-old client has cholelithiasis and is admitted for an elective cholecystectomy. The client is 5 feet 3 inches tall, weighs 205 pounds, and has smoked one pack of cigarettes per day for 35 years. The client will be NPO at midnight. When the client's spouse asks why the client cannot have breakfast the morning before surgery, the nurse should explain:
- A. Your spouse is a good-sized person and it won't hurt to miss breakfast.
- B. Eating breakfast and having food in the stomach could cause vomiting and aspiration during surgery.
- C. Your spouse will be too busy in the morning preparing for surgery to have time to eat breakfast.
- D. Not eating breakfast will prevent fecal contamination of the abdominal operative site.
Correct Answer: B
Rationale: The client's size has nothing to do with an NPO status. Clients are at greatest risk for aspiration and vomiting during surgery when food and/or liquids are in the stomach. Preparation on the morning of surgery is time consuming, but it does not affect a client's NPO status. The gallbladder lies under the surface of the liver and is a part of the biliary tract, not the intestinal tract. Cholecystectomy does not involve the intestinal tract or its contents.