Nokea
The client with obsessive-compulsive disorder (OCD) is asking for help with the repetitive behaviors. The nurse knows that these are a method of dealing with:
- A. Fearful situations
- B. Depression
- C. Delusions
- D. Anxiety
Correct Answer: D
Rationale: The correct answer is D: Anxiety. Repetitive behaviors in OCD serve as a way for individuals to cope with their anxiety. These behaviors are often performed to reduce the distress caused by obsessive thoughts. Choice A, fearful situations, is incorrect because the behaviors are more related to managing anxiety rather than fear itself. Choice B, depression, is incorrect as OCD behaviors are not typically a method of coping with depression. Choice C, delusions, is also incorrect as these behaviors are not aimed at managing delusional thoughts but rather anxiety in OCD.
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The client is admitted with a period of unobserved loss of consciousness and now has an EEG scheduled this morning. What should the nurse implement?
- A. Keep NPO and hold medication.
- B. Hold sedatives, but allow the client to have breakfast and give other medicines.
- C. Administer medications, but hold anticonvulsants.
- D. Give additional fluids and some caffeine prior to the test.
Correct Answer: C
Rationale: Prior to an EEG, it is essential for the client to eat to prevent a drop in blood sugar levels. The nurse should hold sedatives but allow the client to have breakfast and administer other necessary medications. Holding sedatives is crucial to ensure accurate EEG results, while providing breakfast helps maintain stable blood sugar levels. Administering other medications, excluding sedatives, is important for the client's overall care. Choices A, C, and D are incorrect because keeping the client NPO and holding medications, administering medications but holding anticonvulsants, and giving additional fluids and caffeine are not appropriate actions before an EEG.
The nurse observes a nursing assistant performing AM care for a client with a new leg cast. Which action by the assistant will the nurse intervene?
- A. Lifting the affected leg with the palms of the hands
- B. Covering the affected leg with a blanket to avoid chills
- C. Placing plastic over the groin prior to bathing
- D. Elevating the casted leg on two pillows
Correct Answer: B
Rationale: The correct answer is to intervene when the assistant covers the affected leg with a blanket to avoid chills. A new cast should not be covered to allow the heat from the cast to evaporate, preventing complications. Lifting the affected leg with the palms of the hands is appropriate for proper handling. Placing plastic over the groin prior to bathing is a standard practice to protect the client's privacy and maintain hygiene. Elevating the casted leg on two pillows helps reduce swelling and promote circulation, making it a suitable action.
What type of diet is appropriate for a client with chronic cirrhosis?
- A. High calorie, low protein
- B. High protein, high calorie
- C. Low fat, low sodium
- D. High calorie, low sodium
Correct Answer: A
Rationale: The correct diet for a client with chronic cirrhosis is high calorie, low protein. Cirrhosis can lead to impaired protein metabolism, making it essential to limit protein intake. High-calorie foods help meet the client's energy needs. Choice B (High protein, high calorie) is incorrect because high protein intake can worsen hepatic encephalopathy. Choice C (Low fat, low sodium) is not the most appropriate diet for cirrhosis as the focus should be on calories and protein. Choice D (High calorie, low sodium) does not address the need to restrict protein intake, which is crucial in cirrhosis.
When auscultating breath sounds, the nurse auscultates over the following locations:
- A. Trachea and lateral areas of thoracic cage
- B. Anterior and posterior aspects of all lung fields
- C. The mid section as well as the lateral section of the lungs
- D. The mid-clavicular to mid-axillary lines comparing side to side
Correct Answer: B
Rationale: The correct answer is B: Anterior and posterior aspects of all lung fields. When auscultating breath sounds, it is essential to listen to the front (anterior) and back (posterior) aspects of all lung fields. This comprehensive approach allows for a thorough assessment of breath sounds throughout the lungs. Choices A, C, and D are incorrect. Choice A is too limited as it only focuses on the trachea and lateral areas, not covering all lung fields. Choice C is also too limited, referring to specific sections of the lungs (mid section and lateral section). Choice D is incorrect as it suggests comparing specific lines on the chest (mid-clavicular to mid-axillary), which is not a standard practice for auscultating breath sounds.
Which infection control measure is the priority for the nurse to implement in the care provided for a child admitted to the hospital with bacterial meningitis?
- A. Place the child in a private room
- B. Gowns and masks must be worn by all personnel in the child's room
- C. Visitors are restricted to parents only
- D. Hand washing is required by all personnel and visitors having contact with the child
Correct Answer: B
Rationale: The priority control measure for the nurse to implement in caring for a child with bacterial meningitis is ensuring that gowns and masks are worn by all personnel in the child's room. This measure is crucial as the child with bacterial meningitis is contagious for at least 24 hours after starting antibiotics, necessitating airborne precautions to prevent the spread of infection to healthcare workers and other patients. Placing the child in a private room (Choice A) is important but secondary to preventing infection transmission. Restricting visitors to parents only (Choice C) is also significant but not as critical as ensuring proper infection control measures. While hand washing (Choice D) is essential, the immediate need to prevent airborne transmission in the child's room takes precedence.