Nokea
Which type of behavior modification is most likely to benefit a client who has a severe phobia regarding spiders?
- A. Positive reinforcement
- B. Negative reinforcement
- C. Desensitization
- D. Aversion therapy
Correct Answer: C
Rationale: Desensitization (C), gradually exposing the client to spiders, is most effective for phobias. Other methods (A, B, D) are less specific.
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A client with Alzheimer's disease has been prescribed donepezil (Aricept). Which information should the nurse include in the teaching plan for a client on Aricept?
- A. Take the medication with meals.'
- B. The medicine can cause dizziness, so rise slowly.'
- C. If a dose is skipped, take two the next time.'
- D. The pill can cause an increase in heart rate.'
Correct Answer: B
Rationale: Donepezil can cause dizziness due to its cholinergic effects, so clients should rise slowly to prevent falls. It's taken at bedtime, not with meals, and doses shouldn't be doubled.
Which one of the following infants needs a further assessment of growth?
- A. 4-month-old: birth weight 7 lb, 6 oz; current weight 14 lb, 4 oz
- B. 2-week-old: birth weight 6 lb, 10 oz; current weight 6 lb, 12 oz
- C. 6-month-old: birth weight 8 lb, 8 oz; current weight 15 lb
- D. 2-month-old: birth weight 7 lb, 2 oz; current weight 9 lb, 6 oz
Correct Answer: B
Rationale: The 2-week-old has only gained 2 oz since birth, which is inadequate (normal is 0.5-1 oz/day), indicating a need for growth assessment.
The physician has ordered nitroglycerin buccal tablets for a client with stable angina. The nurse knows that nitroglycerin:
- A. Slows contractions of the heart
- B. Dilates coronary blood vessels
- C. Increases the ventricular fill time
- D. Strengthens contractions of the heart
Correct Answer: B
Rationale: Nitroglycerin dilates coronary blood vessels, improving blood flow to the myocardium and relieving angina.
An ICU nurse monitors a client recovering from a head injury. The client's intracranial pressure (ICP) has been between 15 and 19 mmHg throughout the shift. However, after the nurse suctions the client's endotracheal tube, the ICP jumps to 28 mmHg. It decreases a few minutes later to 20 mmHg. The best intervention by the nurse is to
- A. increase the rate of the sedative IV drip.
- B. chart the findings and continue to monitor the client.
- C. reposition the client.
- D. contact the physician.
Correct Answer: D
Rationale: A sudden ICP spike to 28 mmHg post-suctioning suggests a significant issue (e.g., impaired cerebral perfusion). The physician should be contacted for evaluation.
When assessing a client's skin, the nurse notes a scattered red rash on the trunk. The individual lesions are about 0.5 cm in diameter and are flat, nonpalpable, and circumscribed. How would this type of lesion be classified?
- A. Papule
- B. Nodule
- C. Macule
- D. Patch
Correct Answer: C
Rationale: A flat, nonpalpable lesion ≤1 cm is a macule (C). Papules (A) are raised, nodules (B) are deeper and larger, and patches (D) are larger flat lesions.