Nokea
Which type of therapy helps clients alter irrational thinking and replace negative self-statements with positive ones?
- A. Desensitization therapy
- B. Behavioral therapy
- C. Cognitive therapy
- D. Psychobiologic therapy
Correct Answer: C
Rationale: Cognitive therapy focuses on identifying and challenging irrational beliefs, helping clients develop healthier thought patterns.
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What nursing measure assumes priority for Mr. Johnson with sudden diarrhea and high fever?
- A. Determine if he had been working on an air-conditioning unit of a high-rise building
- B. Place the patient in isolation
- C. Monitor respiratory status carefully and observe for signs of hypoxia
- D. Begin discharge teaching
Correct Answer: C
Rationale: The correct answer is C, to monitor respiratory status and observe for signs of hypoxia. This is because sudden diarrhea and high fever can indicate a potential infectious illness, which can lead to respiratory complications such as pneumonia. Monitoring respiratory status is crucial to detect any signs of respiratory distress or hypoxia early on.
A: Determining his work on an air-conditioning unit is not a priority at this time as it does not directly address his immediate health concerns.
B: Placing the patient in isolation may be necessary later depending on the diagnosis, but it is not the priority at this moment.
D: Beginning discharge teaching is not appropriate as the patient is currently experiencing acute symptoms that require immediate attention.
In summary, monitoring respiratory status is the priority to ensure early detection and intervention for any potential respiratory complications in a patient with sudden diarrhea and high fever.
9. When the family members of a postoperative patient leave after a visit, the patient tells the nurse that his family gave him a headache by fussing over him so much. What is an appropriate intervention by the nurse?
- A. Administer the PRN analgesic prescribed for his postoperative pain.
- B. Ask the patient’s permission to use acupressure to ease his headache.
- C. Reassure the patient that his headache will subside now that his family has gone.
- D. Teach the patient biofeedback methods to relieve his headaches by controlling cerebral blood flow.
Correct Answer: B
Rationale: Asking the patient’s permission to use acupressure (option B) is an appropriate non-pharmacological intervention that respects patient autonomy and may effectively alleviate the headache.
Which actions are done primarily by an informatics nurse (select all that apply)?
- A. Designs and builds computer systems
- B. Studies the validity of nursing information
- C. Trains health care providers to provide nursing care
- D. Communicates and accesses information for nursing staff
Correct Answer: A
Rationale: Informatics nurses focus on designing systems, validating information, and building tools to support nursing processes.
Priority Decision: When the nurse asks a preoperative patient about allergies, the patient reports a history of seasonal environmental allergies and allergies to a variety of fruits. What should the nurse do next?
- A. Note this information in the patient's record as hay fever and food allergies.
- B. Place an allergy alert wristband that identifies the specific allergies on the patient.
- C. Ask the patient to describe the nature and severity of any allergic responses experienced from these agents.
- D. Notify the anesthesia care provider (ACP) because the patient may have an increased risk for allergies to anesthetics.
Correct Answer: C
Rationale: Understanding the nature and severity of allergies helps in planning appropriate perioperative care and avoiding potential allergens.
When a client is having a general tonic clonic seizure, the nurse should:
- A. Hold the client's arms at their side.
- B. Place the client on their side.
- C. Insert a padded tongue blade in client's mouth.
- D. Elevate the head of the bed.
Correct Answer: B
Rationale: Placing the client on their side prevents aspiration.