Answer B. The nurse is responsible for maintaining confidentiality of this disclosure by the client.
Answer B. Pets are discouraged when parents are trying to allergy-proof a home for a child with bronchial asthma, unless the pets are kept outside. Pets with hair or feathers are especially likely to trigger asthma attacks. A fish would be a satisfactory pet for this child, but the parents should be taught to keep the fish tank clean to prevent it from harboring mold
Answer B. Under the policy for valuables, the nurse documents the description on an envelope with the client, the client and nurse sign the envelope, and the valuables envelope is locked in the safe. The other options increase the risk of loss or damage to the client’s valuables.
Answer A. Sucking provides the infant with a sense of security and comfort. It also is an outlet for releasing tension. The infant should not be discouraged from sucking on the pacifier. Fussiness and irritability after feeding may indicate that the infant’s appetite is not satisfied. Sucking is not manipulative in the sense of seeking parental attention.
Answer D. In a life-threatening emergency where time is of the essence in saving life or limb, a consent is not required. This client has a Glasgow Coma Scale score of 7, which means he is comatose. The client has deteriorated to a level where he cannot be aroused; withdraws in a purposeless manner from painful stimuli; exhibits decorticate posturing; and may or may not have brain stem reflexes intact. The placement of the ICP monitor is crucial to determine cerebral blood flow and prevent herniation. The client’s fiancée can not sign his consent because, until she is his wife or has designated power of attorney, she is not considered his next of kin. The physician should insert the catheter in this emergency. He does not need to get a consultation from one other physician. When a consent is needed for a situation that is not a true emergency, two nurses can receive a verbal consent by telephone from the client’s next of kin.
Answer D. Follow-up generally involves semiannual chest radiographs. Recurrence usually occurs locally in the lungs and may be identified on chest radiographs. Follow-up after cancer treatment is an important component of the treatment plan. Serum markers (eg, liver function tests) have not been shown to detect recurrence of lung cancer. There are no data to support the need for an abdominal CT scan.
Answer A. All blood products should be administered through a micron mesh filter. Blood is never administered without a filter. Leukocytes can be removed by using leukocyte-poor filters, and this is recommended to decrease reactions in clients such as hemophiliacs who require frequent transfusions. Blood is too concentrated to administer through a microdrip set.
Answer C. STDs are communicable diseases that must be reported. The nurse is responsible for reporting these diseases to the appropriate public health agency, and to otherwise maintain the client’s confidentiality. The client’s family cannot request release of medical information without the client’s consent. A physician’s order is not a substitute for a client’s consent to release medical information in the absence of a communicable disease.
Answer C. One of the best strategies to help clients feel in control is to ask them their view of situations, and to respond to what they say. This technique acknowledges that clients’ opinions have value and relevance to the interview. It also promotes an active role for clients in the process. Use of a questionnaire or written instructions is a means of obtaining information but promotes a passive client role. Asking whether the client has questions encourages client participation, but alone it does not acknowledge the client’s views.
Answer C. A client with severe depression may experience symptoms of psychosis such as hallucinations and delusions that are typically mood congruent. The statement, “My heart has stopped and my blood is black ash,” is a mood-congruent somatic delusion. A delusion is a firm, false, fixed belief that is resistant to reason or fact. A hallucination is a false sensory perception unrelated to external stimuli. An illusion is a misinterpretation of a real sensory stimulus. Paranoia refers to suspiciousness of others and their actions.
Answer B. The client should be allowed to see his chart. As a client advocate, the nurse should answer questions for the client. The nurse helps the client understand that he is a primary partner in the health team. The Bill of Rights for Patients has existed since the 1960s, and every client should be aware of this document. The doctor should not need to give permission for the client to see his chart. As a client advocate, the nurse should not make excuses to put the client off in regard to seeing his chart.
Answer C. The three-point gait, in which the client advances the crutches and the affected leg at the same time while weight is supported on the unaffected extremity, is the appropriate gait of choice. This allows for non–weight bearing on the affected extremity. The two-point, four-point, and swing-to gaits require some weight bearing on both legs, which is contraindicated for this client.
Answer A. When the client verbalizes that life isn’t worth living anymore, the nurse needs to ask the client directly about suicide by saying, “Are you thinking about killing yourself?” Asking directly does not provoke suicide but conveys concern, understanding, and the worth of the client. Often, the client experiences a sense of relief that someone finally hears him. It also helps the nurse plan responsible care by identifying the client who is at risk for suicide. The nurse would then evaluate the seriousness of the suicidal ideation by inquiring about the intent and plan. Stating, “Things will get better,” offers hope too soon without first evaluating the intent of the suicidal ideation. Asking, “Why do you think that way,” implies a lack of understanding and knowledge on the part of the nurse. Major depression usually is endogenous and biochemically based. Therefore, the client may not know why he doesn’t want to live. Saying, “You shouldn’t feel that way,” admonishes the client, decreases self-worth, and conveys a lack of understanding.
Answer A, C and D. Lamotrigine (Lamictal), an antiepileptic, is used as a mood stabilizer for clients with bipolar disorder and has been found to be effective for the depressive phase of bipolar disorder. Common adverse effects are dizziness, headache, sedation, tremor, nausea, vomiting, and ataxia. The development of a rash needs to be reported and evaluated by the physician because it could indicate the start of a severe systemic rash known as Stevens-Johnson syndrome, a toxic epidermal necrolysis, which would necessitate the discontinuance of lamotrigine. Hyperthermia in conjunction with muscle rigidity suggests the development of the neuroleptic malignant syndrome, a life-threatening complication associated with olanzapine.
Answer A. 0.4 mg/x = 0.5 mg/1 mL 0.4 = 0.5x 0.4/0.5 = x 0.8 ml = x.
Answer D. The nurse should instruct the client to increase her intake of calcium because there is a slight increase in the risk of osteoporosis with this medication. Weight-bearing exercises are also advised. The drug may also impair glucose tolerance in women who are at risk for diabetes.
Answer A, B and D. The first trimester is when the couple works through the psychological task of accepting the pregnancy. These statements describe the client and her partner coping with the pregnancy, how it feels, and how it will impact their lives. The feelings include pleasure, excitement and ambivalence. Wondering what the baby will look like and planning for the baby’s room occur later in the pregnancy.
Answer D. The aminoglycoside antibiotic gentamicin sulfate (Garamycin) should not be applied to large denuded areas because toxicity and systemic absorption are possible. The nurse should instruct the client to avoid excessive sun exposure because gentamicin sulfate can cause photosensitivity. The client should be instructed to apply the antibiotic cream or ointment for only the length of time prescribed, because a superinfection can occur from overuse. The client should contact the physician if the condition worsens after use.
Answer C. The nurse needs to inform the sister that there is a lag time of 2 to 4 weeks before a full clinical effect occurs with the drug. The nurse should let her know that her brother will gradually get better and symptoms of depression will improve. Telling the sister that her brother is experiencing a very serious depression does not give the sister important information about the medication. Additionally, this statement may cause alarm and anxiety. Conveying the sister’s concern to the physician does not provide her with the necessary information about the client’s medication. Telling the sister that the client’s medication may need to be changed is inappropriate because a full clinical effect occurs after 2 to 4 weeks.
Answer C. For the client with grandiose delusions, the nurse would accept the client but not argue with the delusion to build trust and the client’s self-esteem. Focusing on the underlying feeling or meaning of the delusion helps to meet the client’s needs. Focusing on events and topics based in reality distracts the client from the delusional thinking. Confronting the client’s delusions or beliefs can lead to agitation in the client and the need to cling to the grandiose delusion to preserve self-esteem. Interacting with the client only when he is based in reality ignores the client’s needs and therapeutic nursing intervention.
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