Nokea
A 47-year-old woman comes to the outpatient psychiatric clinic for treatment of a fear of heights.
Which of the following is the best plan of care that would meet the needs of this client INITIALLY?
- A. Point out to the client the secondary gain that results from her behavior.
- B. Demonstrate to the client the irrational nature of these fears.
- C. Encourage the client to rely on significant others for support.
- D. Allow the client to avoid the situations that are anxiety provoking.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) secondary gain (attention and assistance received) is not the motivation of a phobic patient, remain nonjudgmental (2) ineffective in relieving behavior, may increase anxiety and feelings of guilt (3) should encourage patient to remain independent (4) correct-phobia is fixed channel for discharge of tension from unconscious conflict
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In caring for an elderly client with a depressed affect, which of the following nursing actions would be MOST appropriate to help the client to complete activities of daily living?
- A. Medicate the client before the activities begin.
- B. Develop a written schedule of activities, allowing extra time.
- C. Assist the client with grooming activities so it doesn't take as long.
- D. Provide frequent forceful direction to keep the client focused.
Correct Answer: B
Rationale: written schedule with built-in extra time will allow client to understand what is expected and will allow him to participate at a slower pace
The nurse is teaching a client with a new diagnosis of osteoporosis about calcitonin (Miacalcin). Which of the following statements by the client indicates a need for further teaching?
- A. I should report nasal irritation to my doctor.
- B. I should take this medication at bedtime.
- C. I should alternate nostrils when using the nasal spray.
- D. I should stop this medication if my bone density improves.
Correct Answer: D
Rationale: Stopping calcitonin when bone density improves is incorrect, as osteoporosis often requires ongoing treatment to maintain bone health. Options A, B, and C are correct: nasal irritation is a side effect, bedtime dosing is standard, and alternating nostrils prevents irritation.
The nurse has just received report from the previous shift.
Which of the following clients should the nurse see FIRST?
- A. A client who is receiving a blood transfusion and complains of a dry mouth.
- B. A client who is scheduled to receive heparin and the PTT is 70 seconds.
- C. A client who is receiving hydroloxacin (Cipro) and complains of a high.
- D. A client who is receiving IV potassium and complains of burning at the IV site.
Correct Answer: C
Rationale: Strategy: Determine the least stable client. (1) not an immediate concern (2) PTT is within normal limits, should give medication (3) correct-indicates hypersensitivity reaction, should stop medication and notify the physician (4) should decrease rate to prevent irritation of the vein
A client is admitted with a diagnosis of trigeminal neuralgia (tic douloureux) involving the maxillary branch of the affected nerve. When performing client teaching, it is MOST important for the nurse to include which of the following instructions?
- A. Report an increase in blurred vision.
- B. Eat soft, warm foods.
- C. Change positions slowly.
- D. Chew food on the affected side.
Correct Answer: B
Rationale: intense facial pain experienced along nerve tract is characteristic of this condition; nursing care should be directed toward preventing stimuli to the area and decreasing pain
The nurse cares for an 8 lb, 8 oz newborn boy. The infant's history indicates that his mother was given magnesium sulfate IV 4 g in 250 ml D5W several hours before delivery. The nurse would be MOST concerned if which of the following was observed?
- A. Temperature 97.6°F (36.5°C).
- B. Apical pulse 140 bpm.
- C. Respirations 18.
- D. BP 80/50.
Correct Answer: C
Rationale: magnesium sulfate can cause slowing of respirations and hyporeflexia; normal respirations 30-60/min