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"A nurse's neighbor complains of severe right flank pain. She explains that it
began during the night, but she was able to take acetaminophen (Tylenol) and
return to bed. When she awoke, the pain increased in intensity. How should
the nurse intervene?
1. Explain that she can't give medical advice.
2. Inform the neighbor that she might require surgery.
3. Advise the neighbor to seek medical attention.
4. Tell the neighbor that she'll be fine because she was able to get through
the night. - Correct answer Correct Answer: 3
RATIONALES: The nurse should advise the neighbor to seek medical attention.
Explaining that she can't give medical advice might cause a delay in treatment.
It's beyond the nurse's scope of practice to suggest that the neighbor might
need surgery. Telling the neighbor she'll be fine might also delay treatment,
and it isn't a professional response."
"A client has a history of chronic undifferentiated schizophrenia. Because she
has a history of noncompliance with antipsychotic therapy, she'll receive
fluphenazine decanoate (Prolixin Decanoate) injections every 4 weeks. Before
discharge, what should the nurse include in her teaching plan?
1. Asking the physician for droperidol (Inapsine) to control any extrapyramidal
symptoms that occur
2. Sitting up for a few minutes before standing to minimize orthostatic
hypotension
3. Notifying the physician if her thoughts don't normalize within 1 week
4. Expecting symptoms of tardive dyskinesia to occur and to be transient -
Correct answer Correct Answer: 2
RATIONALES: The nurse should teach the client how to manage common
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,adverse reactions, such as orthostatic hypotension and anticholinergic effects.
The antipsychotic effects of the drug may take several weeks to appear.
Droperidol increases the risk ofextrapyramidal effects when given in
conjunction with phenothiazines such as fluphenazine. Tardive dyskinesia is a
possible adverse reaction and should be reported immediately."
"One day after being admitted with bipolar disorder, a client becomes verbally
aggressive during a group therapy session. Which response by the nurse would
be therapeutic?
1. "You're behaving in an unacceptable manner, and you need to control
yourself."
2. "If you continue to talk like that, no one will want to be around you."
3. "You're disturbing the other clients. I'll walk with you around the patio to
help you release some of your energy."
4. "You're scaring everyone in the group. Leave the room immediately." -
Correct answer Correct Answer: 3
RATIONALES: This response shows that the nurse finds the client's behavior
unacceptable, yet still regards the client as worthy of help. The other options
give the false impression that the client is in control of the behavior; the client
hasn't been in treatment long enough to control the behavior."
"A client comes to the emergency department complaining of headache,
malaise, chills, fever, and a stiff neck. Vital sign assessment reveals a
temperature elevation, increased heart and respiratory rates, and normal
blood pressure. On physical examination, the nurse notes confusion, a
petechial rash, nuchal rigidity, Brudzinski's sign, and Kernig's sign. What does
Brudzinski's sign indicate?
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,1. Increased intracranial pressure (ICP)
2. Cerebral edema
3. Low cerebrospinal fluid (CSF) pressure
4. Meningeal irritation - Correct answer Correct Answer: 4
RATIONALES: Brudzinski's sign indicates meningeal irritation, as in meningitis.
Other signs of meningeal irritation include nuchal rigidity and Kernig's sign.
Brudzinski's sign doesn't indicate increased ICP, cerebral edema, or low CSF
pressure."
"During a routine examination, the nurse notes that the client seems unusually
anxious. Anxiety can affect the genitourinary system by:
1. slowing the glomerular filtration rate.
2. increasing sodium resorption.
3. decreasing potassium excretion.
4. stimulating or hindering micturition. - Correct answer Correct Answer: 4
RATIONALES: Anxiety may stimulate or hinder micturition. Its most noticeable
effect is to cause frequent voiding and urinary urgency. However, when anxiety
leads to generalized muscle tension, it may hinder urination because the
perineal muscles must relax to complete micturition. Anxiety doesn't slow the
glomerular filtration rate, increase sodium resorption, or decrease potassium
excretion."
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, "The nurse is advising a mother about foods to avoid to prevent choking in her
toddler. Which foods should she include in her instruction?
1. Small pieces of banana
2. Large, round chunks of meat such as hot dog
3. Cooked vegetables such as lima beans and corn
4. Frozen desserts such as ice cream - Correct answer Correct Answer: 2
RATIONALES: The nurse should advise the mother to avoid giving her child
large, round chunks of meat such as hot dog. The mother can safely give the
toddler small pieces of banana; cooked vegetables, such as lima beans and
corn; and frozen desserts such as ice cream."
"A client with a history of Addison's disease and flulike symptoms
accompanied by nausea and vomiting over the past week is brought to the
facility. The client's wife reports that she noticed that he acted confused and
was extremely weak when he woke up in the morning. The client's blood
pressure is 90/58 mm Hg, his pulse is 116 beats/minute, and his temperature
is 101° F (38.3° C). A diagnosis of acute adrenal insufficiency is made. Which of
the following would the nurse expect to administer by I.V. infusion?
1. Insulin
2. Hydrocortisone
3. Potassium
4. Hypotonic saline - Correct answer Correct Answer: 2
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