Nokea
While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client?
- A. Compulsive behavior
- B. Sense of impending doom
- C. Fear of flying
- D. Predictable episodes
Correct Answer: B
Rationale: Sense of impending doom. The feeling of overwhelming and uncontrollable doom is characteristic of a panic attack.
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An involuntary psychiatric patient asks the nurse to mail his letter to the President. He states that the letter will make the President regret his actions to prevent homosexuals from serving in the military. Which of the following responses by the nurse is BEST?
- A. Accept the letter and place it in the patient's medical record.
- B. Read the patient's letter and decide if it is appropriate to mail.
- C. Call the patient's psychiatrist and inform him of the letter.
- D. Discourage the patient from sending the letter, but mail it if patient insists.
Correct Answer: D
Rationale: Mailing the letter respects the patient’s communication rights while addressing potential concerns. Options A, B, and C violate autonomy or privacy.
An adult who has COPD is to start receiving oxygen at home. What teaching is essential for this client and his family?
- A. The client should wear synthetic clothes as much as possible.
- B. Oxygen flow should be 6 L/min.
- C. The wall-to-wall carpets should be covered with a cotton sheet where the client walks.
- D. If the client gets short of breath, the oxygen level should be increased 1 L at a time until breathing is easier.
Correct Answer: D
Rationale: Adjusting oxygen flow incrementally for shortness of breath ensures safety, as fixed 6 L/min may be excessive, synthetic clothes increase static risk, and carpet covering is unnecessary.
The nurse is caring for a client who is receiving IV vancomycin for a methicillin-resistant Staphylococcus aureus (MRSA) infection. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 88 bpm.
- C. Redness at the IV site.
- D. Urine output of 50 mL/hour.
Correct Answer: C
Rationale: Redness at the IV site suggests phlebitis or infiltration, which can lead to tissue damage or reduced vancomycin delivery, requiring immediate action. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 50 mL/hour indicate stability.
A 25-year-old primigravida with type I diabetes mellitus.
The nurse explains to the client that her insulin needs will
- A. increase during pregnancy and decrease after delivery.
- B. decrease during pregnancy and increase after delivery.
- C. increase during pregnancy and remain increased after delivery.
- D. decrease during pregnancy and fluctuate after delivery.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-needs increase during pregnancy due to hormonal interference in glucose metabolism (2) needs increase during pregnancy due to hormonal interference in glucose metabolism (3) insulin needs will decrease after delivery (4) needs increase during pregnancy
The nurse is caring for a client with a history of myocardial infarction.
- A. Which instruction is most important for a client post-myocardial infarction?
- B. Avoid heavy lifting for 6 weeks.
- C. Take nitroglycerin only when chest pain occurs.
- D. Resume normal activity immediately.
- E. Monitor blood pressure weekly.
Correct Answer: A
Rationale: Avoiding heavy lifting for 6 weeks prevents cardiac strain during myocardial healing. Nitroglycerin is used for angina, gradual activity resumption is advised, and blood pressure monitoring is routine but secondary.