Nokea
Which of the following nursing observations documented in the client's chart MOST clearly indicates the client's mood?
- A. Client states, 'I see snakes climbing on the walls at all times of the day.'
- B. Unable to sustain a train of thought for long periods of time during history-taking.
- C. Clenches her fists and shouts in an angry tone of voice when asked about family problems.
- D. Is unaware of where she is, what day and year it is, or what time it is.
Correct Answer: C
Rationale: gives data that reflect client's feelings, tone, and behavior associated with those feelings, as well as content area of conversation that evoked that mood
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Which of the following statements, if made to the nurse, indicates parental understanding about the cause of their newborn's diagnosis of cystic fibrosis (CF)?
- A. The gene came from my husband's side of the family.
- B. The gene came from my wife's side of the family.
- C. There is a 50 percent chance that our next child will have the disease.
- D. Both of us carry a recessive trait for cystic fibrosis.
Correct Answer: D
Rationale: cystic fibrosis is inherited by an autosomal recessive trait
A 50-year old man who attends an outpatient clinic is taking chlorpromazine hydrochloride (Thorazine) 100 mg tid. He reports to the nurse that he is sleeping through the day.
What should the nurse do?
- A. Contact the physician to change the dose to 100 mg bid.
- B. Change the time of the medication to 100 mg in the morning, 100 mg after dinner, and 100 mg at hs.
- C. Instruct the man to take frequent naps during the day.
- D. Encourage the man to be more active during the day.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) 300-400 mg/day is needed to treat psychosis (2) correct-will reduce daytime sedation (3) won't decrease sedation from medication (4) won't decrease sedation from medication
The nurse is caring for clients in the outpatient clinic. The nurse returns to the desk and finds four phone messages. Which of the following messages should the nurse return FIRST?
- A. A client with cold symptoms has an oral temperature of 103°F (39.4°C).
- B. A client with stage II decubitus ulcer reports that the dressing has come off.
- C. A client is nauseated and has vomited 6 times in the previous 24 hours.
- D. A client is complaining of leg pain after walking half a mile.
Correct Answer: C
Rationale: assess amount, character, symptoms of fluid volume deficit
The nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following laboratory results should the nurse report immediately?
- A. PTT of 90 seconds.
- B. INR of 1.0.
- C. Platelet count of 150,000/mm^3.
- D. Hemoglobin of 13 g/dL.
Correct Answer: A
Rationale: A PTT of 90 seconds is above the therapeutic range (60–80 seconds), increasing bleeding risk. Options B, C, and D are normal.
The nurse is caring for clients in the hospital. Which of the following nursing activities BEST promotes rest for an elderly hospitalized client?
- A. Place a clock at the bedside.
- B. Restrict visitors so that the client is alone during the evening.
- C. Tell the client how to call for help if needed.
- D. Postpone explanation of further tests that the client will need.
Correct Answer: C
Rationale: elderly client who feels isolated and unable to obtain help if needed cannot rest properly