Nokea
The mother's condition has deteriorated during labor and a cesarean section is required. Her husband is worried and anxious about the changed of plan and demand for an explanation.
Who among the following should explain the procedure to the husband?
- A. The surgeon.
- B. The attending physician.
- C. The primary nurse.
- D. The medical team.
Correct Answer: A
Rationale: The surgeon, as the procedure performer, is best suited to explain the cesarean section.
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A client is sent to the psychiatric unit for forensic evaluation after he is accused of arson. His tentative diagnosis is antisocial personality disorder. In reviewing the client's record, the nurse could expect to find:
- A. A history of consistent employment
- B. A below-average intelligence
- C. A history of cruelty to animals
- D. An expression of remorse for his actions
Correct Answer: C
Rationale: Antisocial personality disorder is associated with a history of cruelty to animals , reflecting disregard for others. Consistent employment and remorse are unlikely. Intelligence is typically average or above.
The nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client would be
- A. Reduce fear and protect self-esteem
- B. Minimize anxiety and delay apprehension
- C. Avoid conflict and leave unpleasant situations
- D. Increase independence and communicate more often
Correct Answer: A
Rationale: Reduce fear and protect self-esteem. Ego defense mechanisms are unconscious proactive barriers that are used to manage instinct and affect in the presence of stressful situations. Healthy reactions are those in which the client admits that they are feeling various emotions.
A nurse is caring for a patient with diabetes mellitus who is experiencing hyperglycemia. Which of the following interventions should the nurse implement? (Select all that apply)
- A. Administer insulin as prescribed
- B. Provide sugar-free fluids
- C. Encourage carbohydrate-rich snacks
- D. Monitor blood glucose levels regularly
- E. Assess for signs of diabetic ketoacidosis (DKA)
Correct Answer: A,B,D,E
Rationale: Insulin corrects hyperglycemia, sugar-free fluids prevent dehydration, monitoring tracks progress, and DKA assessment detects complications. Carbohydrate snacks worsen hyperglycemia.
Teaching about the need to avoid foods high in potassium is most important for which client?
- A. a client receiving diuretic therapy
- B. a client with an ileus
- C. a client with metabolic alkalosis
- D. a client with renal disease
Correct Answer: D
Rationale: Renal disease impairs potassium excretion, leading to hyperkalemia, so avoiding high-potassium foods is critical. The other conditions are more associated with hypokalemia. Physiological Adaptation
The patient is taking antidepressant drug, Elavil. The spouse of the patient complains that the dosage of the drug needs to be increased because no improvement is noted. The patient has been taking the drug for the last 3 days and no improvement is noted.
The most appropriate nursing response would be:
- A. I will inform the physician about your concern.
- B. It may take 3 to 4 weeks for the drug to work.
- C. The drug should work right away.
- D. Possible drug resistant has developed.
Correct Answer: B
Rationale: Elavil, a tricyclic antidepressant, typically takes 3–4 weeks to show therapeutic effects.