A client was admitted to the psychiatric unit after complaining to her friends and family that neighbors have bugged her home in order to hear all of her business. She remains aloof from other clients, paces the floor and believes that the hospital is a house of torture. Nursing interventions for the client should appropriately focus on efforts to
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Solution
Provide interactions to help the client learn to trust staff
Option C: This establishes trust, facilitates a therapeutic alliance between staff and client.
A home health nurse is at the home of a client with diabetes and arthritis. The client has difficulty drawing up insulin. It would be most appropriate for the nurse to refer the client to
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Solution
An occupational therapist from the community center
Option B: An occupational therapist can assist a client to improve the fine motor skills needed to prepare an insulin injection.
A client with schizophrenia is receiving Haloperidol (Haldol) 5 mg t.i.d.. The client’s family is alarmed and calls the clinic when “his eyes rolled upward.” The nurse recognizes this as what type of side effect?
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Solution
Oculogyric crisis
Option A: This refers to involuntary muscles spasm of the eye.
A nurse is caring for a 2-year-old child after corrective surgery for Tetralogy of Fallot. The mother reports that the child has suddenly begun seizing. The nurse recognizes this problem is probably due to
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Solution
A cerebral vascular accident
Option A: Polycythemia occurs as a physiological reaction to chronic hypoxemia which commonly occurs in clients with Tetralogy of Fallot. Polycythemia and the resultant increased viscosity of the blood increase the risk of thromboembolic events. Cerebrovascular accidents may occur. Signs and symptoms include sudden paralysis, altered speech, extreme irritability or fatigue, and seizures.
A client asks the nurse about including her 2 and 12-year-old sons in the care of their newborn sister. Which of the following is an appropriate initial statement by the nurse?
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Solution
“Focus on your son’s” needs during the first days at home.”
Option A: In an expanded family, it is important for parents to reassure older children that they are loved and as important as the newborn.
The nurse is caring for a 13-year-old following spinal fusion for scoliosis. Which of the following interventions is appropriate in the immediate post-operative period?
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Solution
Maintain in a flat position, logrolling as needed
Option C: The bed should remain flat for at least the first 24 hours to prevent injury. Logrolling is the best way to turn for the client while on bed rest.
An infant weighed 7 pounds 8 ounces at birth. If growth occurs at a normal rate, what would be the expected weight at 6 months of age?
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Solution
Double the birth weight
Option A: Although growth rates vary, infants normally double their birth weight by 6 months.
The nurse is teaching parents about the treatment plan for a 2-week-old infant with Tetralogy of Fallot. While awaiting future surgery, the nurse instructs the parents to immediately report
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Solution
Loss of consciousness
Option A: While parents should report any of the observations, they need to call the healthcare provider immediately if the level of alertness changes. This indicates anoxia, which may lead to death. The structural defects associated with Tetralogy of Fallot include pulmonic stenosis, ventricular septal defect, right ventricular hypertrophy and overriding of the aorta. Surgery is often delayed or may be performed in stages.
The parents of a newborn male with hypospadias want their child circumcised. The best response by the nurse is to inform them that
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Solution
Circumcision is delayed so the foreskin can be used for the surgical repair
Option A: Even if mild hypospadias is suspected, circumcision is not done in order to save the foreskin for surgical repair, if needed.
The nurse is caring for a post-surgical client at risk for developing deep vein thrombosis. Which intervention is an effective preventive measure?
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Solution
Encourage range of motion and ambulation
Option C: Mobility reduces the risk of deep vein thrombosis in the post-surgical client and the adult at risk.