Nokea
A client has a total laryngectomy with a permanent tracheostomy.
Which of the following would be necessary for the nurse to consider regarding the client's nutrition?
- A. To facilitate healing of the surgical area, a nasogastric tube may be utilized and tube feedings may be implemented.
- B. The client will be unable to maintain any PO intake as long as he has a tracheotomy in place.
- C. Nutritional and/or gastric feedings will not be attempted for approximately three weeks to decrease the incidence of aspiration.
- D. Since the client is dependent on the ventilator, nutritional intake will be delayed.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-tube feedings frequently started as the initial nutritional intake; prevents trauma to suture area (2) although the client has permanent tracheotomy, will be able to eat normally after area has healed (3) nutritional intake will begin when bowel sounds return and client can tolerate intake (4) client is not dependent on ventilator
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A client in the ICU is given procainamide HCl (Pronestyl) slowly IV push.
- A. Which observation would prompt the nurse to withhold the next dose of procainamide?
- B. Presence of premature ventricular contractions.
- C. Occurrence of severe hypotension.
- D. Recurring paroxysmal atrial tachycardia.
- E. A sedimentation rate of 10.
Correct Answer: B
Rationale: Severe hypotension is a serious side effect of procainamide, requiring the dose to be withheld to prevent cardiovascular collapse. PVCs and atrial tachycardia are arrhythmias the drug treats, and a normal sedimentation rate is irrelevant.
The nurse is caring for an aging client. Which statement the client makes indicates that he is having difficulty with the developmental tasks of aging?
- A. I like to make toys for my grandchildren.'
- B. I used to be a farmer, but now I can't do all that hard work.'
- C. I wish I had changed careers when I really wanted to; now it's too late.'
- D. We don't have as much money now as we did before I retired.'
Correct Answer: C
Rationale: Regret over unfulfilled career changes reflects difficulty achieving ego integrity, the developmental task of accepting one's life. Other statements show adaptation or acceptance.
Which of the following statements reflects Kohlberg's theory of the moral development of the preschool-age child?
- A. Obeying adults is seen as correct behavior.
- B. Showing respect for parents is seen as important.
- C. Pleasing others is viewed as good behavior.
- D. Behavior is determined by consequences.
Correct Answer: D
Rationale: In Kohlberg's preconventional stage (preschoolers), moral behavior is driven by consequences (punishment or reward). Obedience, respect, or pleasing others reflect later stages.
Procrastination, noncompliance, and intentional inefficiency are characteristics of the client with:
- A. Avoidant personality disorder
- B. Antisocial personality disorder
- C. Compulsive personality disorder
- D. Passive aggressive personality disorder
Correct Answer: D
Rationale: Passive aggressive personality disorder is characterized by indirect resistance, such as procrastination and intentional inefficiency.
A postoperative client has pain medication ordered PRN for discomfort. During the first assessment, the nurse notes that the client has not received pain medication all day. His vital signs are within normal limits, but he is sweating profusely. He smiles at you while speaking and states that he is not hot but is still experiencing some pain and has been since early this morning. What is the most appropriate nursing action?
- A. Administer the largest dose of pain medication allowed because he has been without it all day and then allow him to rest undisturbed.
- B. Administer the minimum dose of medication and reassess his level of pain 30 minutes after administration.
- C. Hold the pain medication because his vital signs are within normal limits and he is smiling and showing no evidence of being in pain.
- D. Encourage the client to continue to do without pain medication so he won't become addicted to the opioid.
Correct Answer: B
Rationale: Administering the minimum dose and reassessing ensures effective pain management while monitoring response, given diaphoresis and reported pain.