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When caring for a Native-American family, what does the nurse need to consider?
- A. The family may consist of extended family members beyond parents and children.
- B. Native Americans tend to value their heritage and traditions.
- C. Some Native Americans use herbs and psychologic treatments for illnesses.
- D. Health care practices vary among different tribes and individuals.
Correct Answer: C
Rationale: When caring for a Native-American family, it is crucial to acknowledge and respect their cultural beliefs and practices. Choice A, while relevant, is not as specific as understanding the use of herbs and psychologic treatments in Native American healing practices. Choice B, though generally true, does not directly impact the nursing care provided. Choice D, although true, is too broad and does not focus on the specific aspect of treatment practices. Choice C is the most appropriate answer as it highlights the importance of recognizing and incorporating traditional healing methods into the nursing care plan, promoting culturally sensitive and holistic care.
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The physician has prescribed tranylcypromine sulfate (Parnate) 10mg bid. The nurse should teach the client to refrain from eating foods containing tyramine because it may cause:
- A. Hypertension
- B. Hyperthermia
- C. Melanoma
- D. Urinary retention
Correct Answer: A
Rationale: If the client eats foods high in tyramine, he might experience malignant hypertension. Tyramine is found in cheese, sour cream, Chianti wine, sherry, beer, pickled herring, liver, canned figs, raisins, bananas, avocados, chocolate, soy sauce, fava beans, and yeast. These episodes are treated with Regitine, an alpha-adrenergic blocking agent. Choices B, C, and D are unrelated to the question: Hyperthermia is excessive body temperature, melanoma is a type of skin cancer, and urinary retention is the inability to empty the bladder.
A healthcare provider is preparing to assess the acoustic nerve during a neurological examination. To assess this nerve, the provider uses which technique?
- A. Uses a tuning fork
- B. Asks the client to puff out the cheeks
- C. Tests taste perception on the client's tongue
- D. Checks the client's ability to clench the teeth
Correct Answer: A
Rationale: Testing of cranial nerve VIII (acoustic nerve) involves assessing hearing acuity through techniques like the whispered voice test and tuning fork tests (Weber and Rinne). Using a tuning fork helps determine if sound lateralizes to one ear (Weber) and compares air conduction to bone conduction (Rinne). Asking the client to puff out the cheeks is for cranial nerve VII (facial nerve) function evaluation. Testing taste perception on the tongue assesses cranial nerve IX (glossopharyngeal nerve) function. Checking the ability to clench teeth assesses cranial nerve V (trigeminal nerve) motor function.
Why is the intravenous route potentially the most dangerous route of drug administration?
- A. IV infiltration may occur.
- B. it allows for rapid administration of a drug.
- C. rapid administration of a drug can lead to toxicity
- D. it is the most commonly used route in hospitals.
Correct Answer: C
Rationale: The correct answer is C: rapid administration of a drug can lead to toxicity. When a drug is administered intravenously, it has 100% bioavailability, entering the bloodstream immediately and increasing the risk of toxicity if not carefully monitored. While IV infiltration (choice A) can cause tissue damage, it is not typically life-threatening. Choice B is incorrect as the speed of administration is not the primary reason for the danger; it is the immediate and full dose reaching the bloodstream. Choice D is incorrect as the popularity of the route does not inherently make it more dangerous.
A client reports that someone is in the room and trying to kill him. The nurse's best response is:
- A. "No one is in your room. Let's get you more medicine."?
- B. "I do not see anyone, but you seem to be very frightened."?
- C. "No one can hurt you here."?
- D. "Just tell the person to go away."?
Correct Answer: B
Rationale: When a client reports hallucinations or delusions, it is crucial to respond in a non-confrontational and empathetic manner. Choice B acknowledges the client's fear without confirming the delusion, showing understanding, and providing reassurance. This response validates the client's feelings without reinforcing the false belief. The other responses in choices A, C, and D dismiss the client's feelings or perceptions, which can escalate the situation and harm the therapeutic relationship.
When working with a client diagnosed with Borderline Personality Disorder who frequently attempts self-harm, what is the best intervention to facilitate behavior change?
- A. Constantly observing the client to prevent self-harm.
- B. Enlisting the client in defining and describing harmful behaviors.
- C. Checking on the client every 15 minutes to ensure they are not engaging in harmful behavior.
- D. Removing all items from the environment that the client could use to harm themselves.
Correct Answer: B
Rationale: The most effective intervention when working with clients who have a history of self-harm, like the client diagnosed with Borderline Personality Disorder, is to involve them actively in their treatment. By enlisting the client to define and describe the harmful behaviors, the client becomes an integral part of identifying triggers and understanding the underlying causes of their actions. This approach empowers the client, promotes self-awareness, and fosters a sense of control over their behaviors. Constantly observing the client (Choice A) may lead to a lack of trust and hinder the therapeutic relationship. Checking on the client every 15 minutes (Choice C) may disrupt the client's sense of autonomy and privacy. Removing all items from the environment that could be used for self-harm (Choice D) is a temporary solution and does not address the root causes of the behavior.