Nokea
Which of the following manifestations should the nurse expect?
- A. Drooling
- B. Malaise
- C. Tinnitus
- D. Rhinorrhea
Correct Answer: B
Rationale: The correct answer is B: Malaise. Malaise is a general feeling of discomfort or unease, commonly seen in various health conditions. In this scenario, malaise can be an expected manifestation due to its non-specific nature and association with underlying illnesses. Drooling (A), tinnitus (C), and rhinorrhea (D) are not typically associated with the given context and are less likely to be expected manifestations.
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Which of the following actions should the nurse encourage the client and family to take as they adjust to their new roles?
- A. Implement firm but flexible boundaries in their relationship
- B. Encourage authoritative communication from the adult child
- C. Decrease socialization with extended relatives until roles are identified,
- D. Minimize open discussion regarding the changes to avoid embarrassment.
Correct Answer: A
Rationale: Boundaries foster healthy family dynamics during role adjustments.
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress
- A. Teach the client to use self-talk. Ask, “What kind of drugs have you been taking?â€. Reduce external stimuli. Ask,Have you been sick recently?" Engage with the client several times each day to establish trust"
- B. Brief psychotic disorder. Delirium. Anxiety. Substance use disorder.
- C. Ability to care for self. Fearfulness. Suicide risk. Tremulousness. Temperature
- D. Brief psychotic disorder
Correct Answer:
Rationale: Action to Take: Teach the client to use self-talk, Engage with the client several times each day to establish trust; Potential Condition: Anxiety; Parameter to Monitor: Fearfulness, Suicide risk.
Rationale: The correct actions to take for addressing anxiety would be teaching self-talk and building trust through engagement. Fearfulness and suicide risk are relevant parameters to monitor in assessing the client's progress and response to interventions. These choices align with addressing anxiety and ensuring client safety and well-being.
Incorrect Choices:
- A: "Ask, 'What kind of drugs have you been taking?' and 'Have you been sick recently?' are not appropriate actions for addressing anxiety.
- B: Brief psychotic disorder and delirium are not the potential conditions the client is most likely experiencing.
- C: Monitoring ability to care for self and tremulousness are not the most relevant parameters for assessing anxiety.
The nurse should set the IV infusion pump to deliver how many ml/hr to administer half the total volume in the first 8 hr?
Correct Answer: 255
Rationale: Half of 4,080 mL is 2,040 mL; over 8 hours, this equals 255 mL/hr.
Which of the following dysrhythmias is the client displaying?
- A. First-degree atrioventricular block
- B. Complete heart block
- C. Premature atrial complexes
- D. Atrial fibrillation
Correct Answer: A
Rationale: The correct answer is A: First-degree atrioventricular block. This dysrhythmia is characterized by a delay in conduction at the atrioventricular node, causing a prolonged PR interval (>0.20 sec) on ECG. It is a benign condition and does not typically require treatment unless symptomatic. Choices B and D are more serious dysrhythmias that have different ECG patterns and clinical implications. Complete heart block (Choice B) presents with a lack of conduction between the atria and ventricles, leading to a slow ventricular rate. Atrial fibrillation (Choice D) is characterized by rapid, irregular atrial depolarizations without effective atrial contractions. Premature atrial complexes (Choice C) are early ectopic atrial beats that appear as abnormal P waves on ECG but do not cause significant conduction delays.
Which of the following actions should the nurse take first?
- A. Teach the client how to insert the diaphragm
- B. Document the client's level of understanding about potential adverse effects.
- C. Supervise return demonstration of diaphragm use
- D. Determine the client's knowledge about diaphragm use
Correct Answer: D
Rationale: Assessing the client’s current knowledge is the first step in patient education.