Nokea
Which method is used to verify the placement of a newly inserted central venous access device (CVAD)?
- A. Chest x-ray
- B. Flushing the line with heparin
- C. Withdrawing blood to ensure patency
- D. Chest fluoroscopy
Correct Answer: A
Rationale: The correct method to verify the placement of a newly inserted central venous access device (CVAD) is a chest x-ray. This is crucial to detect any potential complications such as pneumothorax, which can occur during subclavian vein catheter insertion. Symptoms of pneumothorax may include shortness of breath and anxiety. Flushing the line with heparin is not used for placement verification, but rather for maintaining patency after verification. Withdrawing blood to ensure patency is done after placement is confirmed, not for initial verification. Chest fluoroscopy may be used during the insertion process but is not typically employed for placement verification.
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Which reaction toward the physical symptom would the nurse observe in a client with conversion disorder?
- A. Anger
- B. Apathy
- C. Anxiety
- D. Agitation
Correct Answer: B
Rationale: In conversion disorder, the nurse would observe apathy toward the physical symptom. The development of the symptom serves as an unconscious method of reducing anxiety. The symptom is accepted passively, known as 'la belle indifférence.' There is no anger observed as symptoms are passively accepted. Similarly, there is no direct anxiety related to the physical symptom, as the conflict is resolved through the symptom development. While many individuals might experience agitation and seek to identify the cause of physical symptoms, in conversion disorder, there is an unusual calmness or indifference towards the physical manifestation, indicating apathy rather than other emotional responses.
The nurse is caring for a dying client who states, 'Will you be the executor of my will?' How should the nurse best respond to this client?
- A. I must decline your offer because I am your nurse.
- B. I will carry out your will according to your wishes.
- C. It is an honor to be named the executor of your will.
- D. Tell me more so that I can understand your thinking.
Correct Answer: D
Rationale: The client's question reflects his thoughts about the will and how to obtain an executor, but the question does not reveal why the client is asking the nurse to be executor, and it also does not address other important information. In option 4, the nurse seeks clarification while acknowledging the client's statement. Most agencies do not allow the nurse to be the executor of a client's will (option 3). The other options fail to regard the potential consequences, think critically, or explore the client's motivation and needs.
Which dysfunction of the reproductive system is associated with anorexia nervosa in females?
- A. Galactorrhea
- B. Gynecomastia
- C. Amenorrhea
- D. Premenstrual dysphoric disorder
Correct Answer: C
Rationale: Amenorrhea (cessation of menses) is associated with anorexia nervosa in females due to endocrine imbalances resulting from depleted fat stores. Galactorrhea is a milky discharge from the nipples unrelated to normal breast milk production. Gynecomastia is swelling of breast tissue in males. Premenstrual dysphoric disorder occurs about 1 week before menses and includes mood swings, depression, fatigue, bloating, overeating, and difficulty focusing, resolving when menstruation starts. In the context of anorexia nervosa, the primary concern is the disruption of the menstrual cycle due to low body weight, leading to amenorrhea.
The home health nurse visits a client with a history of type 1 diabetes mellitus. The client has recently experienced permanent loss of vision and is having difficulty adjusting. Which action by the nurse is most appropriate?
- A. Ask the health care provider for a psychiatric referral.
- B. Recommend that the client join a support group.
- C. Warn the client that failure to adapt can increase risk for injury.
- D. Reassure client that a change in visual abilities does not change personal identity.
Correct Answer: D
Rationale: Reassuring the client that vision loss does not alter their personal identity addresses emotional adjustment, fostering hope and self-worth. Support groups are helpful but less immediate, and psychiatric referrals or warnings may not address the client’s current emotional needs.
A young adult client diagnosed with a spinal cord injury tells the nurse, 'It's so depressing that I'll never get to have sex again.' Which is the realistic reply for the nurse to make to the client?
- A. It must feel horrible to know you can never have sex again.'
- B. It's still possible to have a sexual relationship, but it will be different.'
- C. You're young, so you'll adapt to this more easily than if you were older.'
- D. Because of body reflexes, sexual functioning will be no different than before.'
Correct Answer: B
Rationale: It is possible to have a sexual relationship after a spinal cord injury, but it is different from what the client will have experienced before the injury. Males may experience reflex erections, although they may not ejaculate. Females can have adductor spasm. Sexual counseling may help the client adapt to changes in sexuality after a spinal cord injury.