1. The client is admitted for evaluation of aggressive behavior and diagnosed with antisocial personality disorder. A key part of the care of such a client is:
A. Setting realistic limits
B. Encouraging the client to express remorse for behavior
C. Minimizing interactions with other clients
D. Encouraging the client to act out feelings of rage
Answer A is correct. Clients with antisocial personality disorder must have limits set on their behavior because they are artful in manipulating others. Answer B is not correct because they do express feelings and remorse. Answers C and D are incorrect because it is unnecessary to minimize interactions with others or encourage them to act out rage more than they already do.
2. A 4-year-old male is admitted to the unit with nephotic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should:
A. Apply ice to the scrotum
B. Elevate the scrotum on a small pillow
C. Apply heat to the abdominal area
D. Administer a diuretic
Answer B is correct. The child with nephotic syndrome will exhibit extreme edema.
Elevating the scrotum on a small pillow will help with the edema. Applying ice is contraindicated; heat will increase the edema. Administering a diuretic might be ordered, but it will not directly help the scrotal edema. Therefore, answers A, C, and D are incorrect.
3. The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin?
A. Cyanocobalamine
B. Protamine sulfate
C. Streptokinase
D. Sodium warfarin
Answer B is correct. The antidote for heparin is protamine sulfate. Cyanocobalamine is B12, Streptokinase is a thrombolytic, and sodium warfarin is an anticoagulant. Therefore, answers A, C, and D are incorrect.
4. The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?
A. The graduate places the client in a supine position to read the manometer.
B. The graduate turns the stop-cock to the off position from the IV fluid to the client.
C. The graduate instructs the client to perform the Valsalva maneuver during the CVP reading.
D. The graduate notes the level at the top of the meniscus..
Answer C is correct. The client should breathe normally during a central venous pressure monitor reading. Answer A indicates understanding because the client should be placed supine if he can tolerate being in that position. Answers B and D indicate understanding because the stop-cock should be turned off to the IV fluid, and the reading should be done at the top of the meniscus.
5. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided?
A. Bran
B. Fresh peaches
C. Cucumber salad
D. Yeast rolls
Answer C is correct. The client with diverticulitis should avoid foods with seeds. The foods in answers A, B, and D are allowed; in fact, bran cereal and fruit will help prevent constipation.
A. Setting realistic limits
B. Encouraging the client to express remorse for behavior
C. Minimizing interactions with other clients
D. Encouraging the client to act out feelings of rage
Answer A is correct. Clients with antisocial personality disorder must have limits set on their behavior because they are artful in manipulating others. Answer B is not correct because they do express feelings and remorse. Answers C and D are incorrect because it is unnecessary to minimize interactions with others or encourage them to act out rage more than they already do.
2. A 4-year-old male is admitted to the unit with nephotic syndrome. He is extremely edematous. To decrease the discomfort associated with scrotal edema, the nurse should:
A. Apply ice to the scrotum
B. Elevate the scrotum on a small pillow
C. Apply heat to the abdominal area
D. Administer a diuretic
Answer B is correct. The child with nephotic syndrome will exhibit extreme edema.
Elevating the scrotum on a small pillow will help with the edema. Applying ice is contraindicated; heat will increase the edema. Administering a diuretic might be ordered, but it will not directly help the scrotal edema. Therefore, answers A, C, and D are incorrect.
3. The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin?
A. Cyanocobalamine
B. Protamine sulfate
C. Streptokinase
D. Sodium warfarin
Answer B is correct. The antidote for heparin is protamine sulfate. Cyanocobalamine is B12, Streptokinase is a thrombolytic, and sodium warfarin is an anticoagulant. Therefore, answers A, C, and D are incorrect.
4. The licensed practical nurse is observing a graduate nurse as she assesses the central venous pressure. Which observation would indicate that the graduate needs further teaching?
A. The graduate places the client in a supine position to read the manometer.
B. The graduate turns the stop-cock to the off position from the IV fluid to the client.
C. The graduate instructs the client to perform the Valsalva maneuver during the CVP reading.
D. The graduate notes the level at the top of the meniscus..
Answer C is correct. The client should breathe normally during a central venous pressure monitor reading. Answer A indicates understanding because the client should be placed supine if he can tolerate being in that position. Answers B and D indicate understanding because the stop-cock should be turned off to the IV fluid, and the reading should be done at the top of the meniscus.
5. The nurse is assisting a client with diverticulosis to select appropriate foods. Which food should be avoided?
A. Bran
B. Fresh peaches
C. Cucumber salad
D. Yeast rolls
Answer C is correct. The client with diverticulitis should avoid foods with seeds. The foods in answers A, B, and D are allowed; in fact, bran cereal and fruit will help prevent constipation.
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