Nokea
What is a priority goal of involuntary hospitalization of the severely mentally ill client?
- A. Re-orientation to reality
- B. Elimination of symptoms
- C. Protection from harm to self or others
- D. Development of self-care skills
Correct Answer: C
Rationale: The correct answer is C: 'Protection from harm to self or others.' Involuntary hospitalization is primarily aimed at ensuring the safety of the individual and others. Re-orientation to reality (choice A) may be a goal of treatment but not the primary goal of involuntary hospitalization. Elimination of symptoms (choice B) and development of self-care skills (choice D) are important aspects of treatment but are secondary to the immediate priority of ensuring safety in cases of severe mental illness.
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Which of the following patients should the home care nurse assess first?
- A. A 65-year-old male with known COPD and difficulty breathing after climbing a flight of stairs.
- B. A 78-year-old with CHF who has gained 4 lbs according to her tele-monitoring.
- C. A 50-year-old with bilateral leg swelling and difficulty walking.
- D. A 60-year-old with lower back pain.
Correct Answer: A
Rationale: The correct answer is A. A patient with known COPD and difficulty breathing after physical exertion like climbing stairs requires immediate assessment by the nurse. This could indicate a potential exacerbation of COPD, which needs prompt intervention to prevent respiratory distress. Choices B, C, and D describe important patient situations that also require attention, but the urgency is higher with a COPD patient experiencing difficulty breathing.
An infant has just returned from surgery for placement of a gastrostomy tube as an initial treatment for tracheoesophageal fistula. The mother asks, 'When can the tube be used for feeding?' The nurse's best response would be which of these comments?
- A. "Feedings can begin in 5 to 7 days."
- B. "The use of the feeding tube can begin immediately."
- C. "The stomach contents and air must be drained first."
- D. "The incision healing must be complete before feeding."
Correct Answer: C
Rationale: The correct answer is C: 'The stomach contents and air must be drained first.' Before starting feedings through a gastrostomy tube, it is essential to drain the stomach contents and air. This process helps prevent complications and ensures the proper functioning of the tube after placement. Choice A is incorrect because initiating feedings within 5 to 7 days may lead to complications if the stomach is not adequately prepared. Choice B is incorrect as feeding should not begin immediately to allow for proper preparation of the tube and the stomach. Choice D is incorrect because although incision healing is important, draining the stomach contents and air is a more immediate concern to prevent complications.
Iwa, two years old, was brought to the health center because of diarrhea for 4 days. Assessment revealed that Iwa has under-nutrition. Which of the following actions will you take?
- A. Advise the mother to give milk and juices between meals at home
- B. Give nutritious food available at home
- C. Refer to the hospital for proper management
- D. Provide mother with ORS solution and show her how to give the solution
Correct Answer: A
Rationale: In the case of a child with under-nutrition and diarrhea, advising the mother to give milk and juices between meals at home is the appropriate action. This helps address the nutritional needs of the child while also providing hydration. Option B, giving nutritious food available at home, may not be sufficient in addressing immediate needs such as dehydration. Option C, referring to the hospital, may be necessary in severe cases but is not the first-line action. Option D, providing ORS solution, is important but does not directly address the under-nutrition concern.
A 16-year-old client is admitted to a psychiatric unit with a diagnosis of attempted suicide. The nurse is aware that the most frequent cause for suicide in adolescents is
- A. Progressive failure to adapt
- B. Feelings of anger or hostility
- C. Reunion wish or fantasy
- D. Feelings of alienation or isolation
Correct Answer: D
Rationale: Feelings of alienation or isolation are common triggers for suicidal behavior in adolescents. This sense of being disconnected or isolated from others can lead to despair and hopelessness, increasing the risk of suicidal ideation. Choices A, B, and C are less commonly associated with suicide in adolescents. Progressive failure to adapt may contribute to stress, but it is not typically the primary cause of suicide. Feelings of anger or hostility, while negative emotions, do not always lead to suicidal behavior in adolescents. Reunion wish or fantasy is not a recognized primary cause of suicide in this age group.
A 67-year-old client is admitted with substernal chest pain with radiation to the jaw. His admitting diagnosis is Acute Myocardial Infarction (MI). The priority nursing diagnosis for this client during the immediate 24 hours is
- A. Constipation related to immobility
- B. High risk for infection
- C. Impaired gas exchange
- D. Fluid volume deficit
Correct Answer: C
Rationale: The correct answer is C: Impaired gas exchange. In a client with an acute myocardial infarction, impaired gas exchange is a priority nursing diagnosis due to compromised heart function, which affects oxygenated blood circulation. Close monitoring and interventions are crucial to ensure adequate oxygenation. Choices A, B, and D are incorrect: A) Constipation related to immobility is not the priority in this acute situation; B) High risk for infection is not the immediate concern related to the client's primary diagnosis; D) Fluid volume deficit, while important, is not the priority compared to addressing impaired gas exchange in acute MI.