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When planning care for the passive-aggressive client, the nurse includes the following goal:
- A. Allow the client to use humor, because this may be the only way this client can express self.
- B. Allow the client to express anger by using 'I' messages, such as 'I was angry when . . .,' etc.
- C. Allow the client to have time away from therapeutic responsibilities.
- D. Allow the client to give excuses if he forgets to give staff information.
Correct Answer: B
Rationale: Ceasing to use humor and sarcasm is a more appropriate goal, because this client uses these behaviors covertly to express aggression instead of being open with anger. Use of 'I' messages demonstrates proper use of assertive behavior to express anger instead of passive-aggressive behavior. Client is expected to complete share of work in therapeutic community because he has often obstructed other's efforts by failing to do his share. Client has used conveniently forgetting or withholding information as a passive-aggressive behavior, which is not acceptable.
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When preparing insulin for IV administration, the nurse identifies which kind of insulin to use?
- A. NPH
- B. Human or pork
- C. Regular
- D. Long acting
Correct Answer: C
Rationale: (A, B, D) Intermediate-acting and long-acting preparations contain materials that increase length of absorption time from the subcutaneous tissues but cause the preparation to be cloudy and unsuitable for IV use. Human insulin must be given SC. Only regular insulin can be given IV.
A 16-month-old infant is being prepared for tetralogy of Fallot repair. In the nursing assessment, which lab value should elicit further assessment and requires notification of physician?
- A. pH 7.39
- B. White blood cell (WBC) count 10,000 WBCs/mm3
- C. Hematocrit 60%
- D. Bleeding time of 4 minutes
Correct Answer: C
Rationale: Normal hematocrit in infant is 28%-42%. A 60% hematocrit may indicate polycythemia, a common complication of cyanotic heart disease.
A client is scheduled for a biologic heart valve replacement. The nurse is aware that the client will require:
- A. Lifelong anticoagulant therapy
- B. Valve replacement every two years
- C. Strict dental hygiene to prevent bacterial infection
- D. Use of electric razor instead of safety razor
Correct Answer: C
Rationale: Biologic (tissue) heart valves are prone to bacterial endocarditis. Strict dental hygiene prevents infections that could seed the valve. Lifelong anticoagulation is typically for mechanical valves and the other options are not specific to biologic valves.
The patient states, 'My stomach hurts about two hours after I eat.' Based upon this information, the nurse suspects the patient likely has a:
- A. Gastric ulcer
- B. Duodenal ulcer
- C. Peptic ulcer
- D. Curling's ulcer
Correct Answer: B
Rationale: Pain 2–3 hours after eating is characteristic of a duodenal ulcer, as acid irritates the ulcerated mucosa in the duodenum post-digestion. Gastric ulcer pain typically occurs sooner after meals, peptic ulcer is a general term, and Curling’s ulcer is stress-related.
The nurse is teaching a client with a history of GERD about dietary modifications. The nurse should tell the client to avoid:
- A. Spicy foods
- B. High-fiber foods
- C. Lean proteins
- D. Fresh fruits
Correct Answer: A
Rationale: Spicy foods can irritate the esophagus and relax the lower esophageal sphincter, worsening GERD symptoms, so they should be avoided.