Nokea
Which of the following guidelines is appropriate for the nurse to give a mother concerning the developmental stage of her seven-year-old daughter?
- A. The child's periods of shyness are to be expected.
- B. Nightmares are not characteristic of this age and should be investigated.
- C. The child should be encouraged to care for her younger sister.
- D. Punishment may be necessary for acts of independence.
Correct Answer: A
Rationale: normal for developmental stage, beginning to show independence from parents
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A nurse is the first on the scene of a motor vehicle accident. The victim has sucking sounds with respirations at a chest wound site and tracheal deviation toward the uninjured side. Until others arrive, the priority nursing action would be to
- A. loosely cover the wound, preferably with a sterile dressing.
- B. place a sandbag over the wound.
- C. monitor chest wound drainage.
- D. place a firm, airtight, sterile dressing over the wound.
Correct Answer: A
Rationale: implementation, in an open pneumothorax, air enters the pleural cavity through an open wound; placing a sterile dressing loosely over the wound allows air to escape but not reenter the pleural space
The nurse is caring for a patient following surgery for a coronary artery bypass graft (CABG). Which of the following symptoms would the nurse expect to see if the patient was in the early stages of circulatory overload?
- A. Change in the character of respirations.
- B. Fluctuation in the blood pressure.
- C. Reduction in tissue turgor.
- D. Increase in body temperature.
Correct Answer: A
Rationale: will see dyspnea, cough, edema, hemoptysis
A client is admitted for treatment of severe anxiety. It is MOST important for the nurse to obtain which of following information during the first 48 hours after admission?
- A. What is important to the client.
- B. How the client views herself.
- C. In what situations the client gets anxious.
- D. If anyone in the client's family has had mental problems.
Correct Answer: C
Rationale: will provide necessary information in baseline assessment of client's anxiety
A client is started on doxepin hydrochloride (Sinequan) 75 mg PO tid. The nurse should recommend a change in the client's therapy if which of the following occurs?
- A. The client refuses to speak and sits quietly in the room.
- B. The client becomes excitable and develops tremors.
- C. The client refuses to eat breakfast.
- D. The client sleeps 18 hours a day.
Correct Answer: B
Rationale: doxepin HCL (Sinequan) is an antidepressant; signs of overdosage include excitability and tremors
The nurse is preparing a 56-year-old woman for a paracentesis. It is MOST important for the nurse to take which of the following actions?
- A. Keep the woman NPO 12 hours before the procedure.
- B. Have the woman void just before the procedure.
- C. Initiate a bowel preparation program 24 hours before the procedure.
- D. Place the woman supine during the procedure.
Correct Answer: B
Rationale: prevents puncture of bladder