Which interventions should the nurse use to assist the clien...

Which interventions should the nurse use to assist the client with grandiose delusions? Select all that apply.

A. Accepting the client while not arguing with the delusion.
B. Focusing on the feelings or meaning of the delusion.
C. Focusing on events and topics based in reality.
D. Confronting the client's beliefs.
E. Interacting with the client only when he is based in reality.

Correct Answer: A,B,C

Rationale: To manage grandiose delusions, the nurse should accept the client without reinforcing the delusion, focus on the underlying feelings, and redirect to reality-based topics. Confronting beliefs or limiting interaction to reality-based moments can escalate agitation or alienate the client.

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A neonate is to receive an I.V. infusion of normal saline solution at 3 mL/hour. The nurse is setting the alarms on an I.V. infusion pump. How should the nurse set the alarms?

A. At 5% above and below the keep-vein-open rate.
B. Within a 15% range of the keep-vein-open rate.
C. To sound when the infusion is infiltrating.
D. At the exact drip rate as prescribed.

Correct Answer: D

Rationale: For precise low-rate infusions like 3 mL/hour, the alarm should be set at the exact rate to ensure accuracy and detect deviations promptly. Infiltration alarms are not standard on most pumps.

A client with a history of cirrhosis is admitted with ascites. The nurse should include which of the following in the plan of care?

A. Administer spironolactone as prescribed.
B. Restrict sodium intake.
C. Encourage a high-carbohydrate diet.
D. Limit fluid intake.

Correct Answer: A, B

Rationale: Spironolactone and sodium restriction reduce fluid retention in ascites.

The nurse is evaluating a diabetic client's understanding of the signs of hyperglycemia. Which statement by the client reflects an understanding?

A. I may become diaphoretic and faint.
B. I may notice signs of fatigue, dry skin, and increased urination.
C. I need to take an extra diabetic pill if my blood glucose is greater than 300.
D. I should restrict my fluid intake if my blood glucose is greater than 250.

Correct Answer: B

Rationale: Fatigue, dry skin, polyuria, and polydipsia are classic symptoms of hyperglycemia. Fatigue occurs because of lack of energy from the inability of the body to use glucose. Dry skin occurs secondary to dehydration related to polyuria. Polydipsia occurs secondary to fluid loss. Diaphoresis is associated with hypoglycemia. A client should not take extra hypoglycemic agents to reduce an elevated blood glucose level. A client with hyperglycemia becomes dehydrated secondary to the osmotic effect of the elevated glucose; therefore, the client must increase fluid intake.

One of the primary purposes of a formal medication reconciliation is to:

A. Prevent polypharmacy
B. Conserve financial resources
C. Prevent interactions
D. Prevent allergies

Correct Answer: C

Rationale: Medication reconciliation compares current and previous medication lists to identify and prevent potential drug interactions, ensuring safe prescribing.

A client with a history of burns is admitted with a 40% total body surface area injury. The nurse should prioritize which of the following interventions?

A. Initiate fluid resuscitation.
B. Administer prophylactic antibiotics.
C. Apply ice to the burns.
D. Cover the burns with dry gauze.

Correct Answer: A

Rationale: Fluid resuscitation is the priority to prevent hypovolemic shock in extensive burns.