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NEW QUESTION 26
Plans for the care of a client with an ulcer caused by emotional problems need to take into consideration that:
- A. The disorder is a threat to his physical well-being
- B. There is no real psychological basis for his illness
- C. His priority needs are limited to medical management
- D. He is unable to participate in planning his care
Answer: A
Explanation:
Explanation/Reference:
Explanation:
(A) There may be a medical emergency that takes top priority; however, the basis of the problem is emotional. (B) The problem is a physical manifestation of an emotional conflict. (C) The bleeding ulcer can be life threatening. (D) For lifestyle change to occur, the client must participate in the planning of his care so that he is committed to changes that will have positive results.
NEW QUESTION 27
A nasogastric (NG) tube inserted preoperatively is attached to low, intermittent suctions. A client with an NG tube exhibits these symptoms: He is restless; serum electrolytes are Na 138, K 4.0, blood pH 7.53. This client is most likely experiencing:
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Hyponatremia
- D. Hyperkalemia
Answer: B
Explanation:
(A) Sodium level is within normal limits. (B) Sodium level is within normal limits. (C) pH level is consistent with alkalosis. (D) With an NG tube attached to low, intermittent suction, acids are removed and a client will develop metabolic alkalosis.
NEW QUESTION 28
A 19-year-old client fell off a ladder approximately 3 ft to the ground. He did not lose consciousness but was taken to the emergency department by a friend to have a scalp laceration sutured. The nurse instructs the client to:
- A. Remove his scalp sutures after 5 days
- B. Take meperidine 50 mg po q4-6h prn for headache
- C. Return to the hospital immediately if he develops confusion, nausea, or vomiting
- D. Clean the sutured laceration twice a day with povidone- iodine (Betadine)
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) Povidone-iodine is very irritating to skin and should not be routinely used. (B) Sutures should not be removed by the client. (C) Confusion, nausea, vomiting, and behavioral changes may indicate increasing intracranial pressure as a result of intracerebral bleeding. (D) Use of a narcotic opiate such as meperidine is not recommended in clients with a possible head injury because it may produce sedation, pupil changes, euphoria, and respiratory depression, which may mask the signs of increasing intracranial pressure.
NEW QUESTION 29
The most important goal in the care plan for a child who was hospitalized with an accidental overdose would be to:
- A. Instruct parents in use of ipecac
- B. Determine child's activity pattern
- C. Teach parents appropriate safety precautions
- D. Reduce mother's sense of guilt
Answer: C
Explanation:
Explanation
(A) This goal is not the most important. (B) There is always some guilt when an accident occurs; however, the priority is to be sure future accidents are prevented. (C) Ipecac is not used for caustic alkali and acid ingestions. (D) Determining the parent's knowledge about safety hazards and teaching appropriate preventive measures are likely to prevent recurrence of accidents.
NEW QUESTION 30
The nurse should facilitate bonding during the postpartum period. What should the nurse expect to observe in the taking-hold phase?
- A. Mother is concerned about her recovery.
- B. Mother is concerned about her weight gain.
- C. Mother lightly touches infant.
- D. Mother calls infant by name.
Answer: D
Explanation:
Explanation
(A) This observation can be made during the taking-in phase when the mother's needs are more important. (B) This observation can be made during the taking-hold phase when the mother is actively involved with herself and the infant. (C, D) This observation can be made during the taking-in phase.
NEW QUESTION 31
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