Nokea
Which of the following behaviors is characteristic of the client with schizoid personality disorder?
- A. Excessive emotional outbursts
- B. Violation of the rights of others
- C. Social detachment
- D. Attention-seeking behaviors
Correct Answer: C
Rationale: Social detachment is a key characteristic of schizoid personality disorder, with individuals preferring solitude and showing little interest in relationships.
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The nurse is caring for a client who had a chest tube inserted and attached to portable water seal drainage two days ago. There is no bubbling in the water seal chamber. What should the nurse assess initially?
- A. Observe the wound for excess drainage
- B. Check the system for air leaks
- C. Auscultate the lungs
- D. See if the suction is turned on
Correct Answer: C
Rationale: No bubbling may indicate lung reexpansion or system issues; auscultating lungs assesses reexpansion or complications like pneumothorax. Other assessments are secondary.
The nurse reviews the admission history of a 70-year-old client diagnosed with chronic obstructive pulmonary disease (COPD). Which of the following statements by the client does the nurse recognize as contributing to the development of COPD? Select all that apply.
- A. I have been drinking alcohol almost daily since age 20.'
- B. I have been overweight for as long as I can remember.'
- C. I have smoked about a pack of cigarettes a day since I was 16 years old but quit last year.'
- D. I know I eat too much fast food.'
- E. I was a car mechanic for about 40 years and had my own garage.'
Correct Answer: C, E
Rationale: Smoking (C) is a primary cause of COPD. Occupational exposure to chemicals as a mechanic (E) is also a risk factor. Alcohol (A), obesity (B), and fast food (D) are not directly linked to COPD.
The nurse is caring for a client with Guillain-Barré syndrome after a recent gastrointestinal illness. Monitoring for which symptom is a nursing care priority in this client?
- A. Diaphoresis with facial flushing
- B. Hypoactive or absent bowel sounds
- C. Inability to cough or lift the head
- D. Warm, tender, and swollen leg
Correct Answer: C
Rationale: Inability to cough or lift the head (C) indicates respiratory muscle weakness, a life-threatening complication in Guillain-Barré syndrome, making it the priority.
The nurse is collecting data from a 10-year-old client during a routine physical examination. Which of the following actions should the nurse take? Select all that apply.
- A. Use correct anatomical terminology while reinforcing teaching about self-care.
- B. Conduct a head-to-toe examination in the same sequence as an adult examination.
- C. Explain the purpose of the examination equipment and any procedures to the client.
- D. Offer the client a gown and allow the client to keep the underwear on during the examination.
- E. Ask the accompanying parent to rate and describe any pain the client may be experiencing.
Correct Answer: A, C, D
Rationale: Using anatomical terminology (A) promotes understanding. Explaining equipment and procedures (C) reduces anxiety. Offering a gown and allowing underwear (D) respects privacy. Adult examination sequences (B) may not suit pediatric needs, and parents rating pain (E) may not accurately reflect the child's experience.
A new client is admitted with a major abscess on her thigh caused by scratching mosquito bites with dirty hands after digging in her garden. She is on isolation precautions in a private room after surgical debridement. The physician changes her dressings daily. What should the nurse wear when providing care for this client?
- A. An N95 respirator and gloves
- B. Eye protection and a face mask
- C. Gloves and gown
- D. A gown only
Correct Answer: C
Rationale: Gloves and gown are required for contact precautions due to the abscess, preventing transmission of infection.