A client with a history of alcoholism cannot remember the events of the past week even though he has receipts from various places of business. The client’s inability to recall events is known as:
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Solution
Answer C is correct. An alcoholic blackout refers to the inability to remember what occurred before or after a period of alcohol intake. Answer A is incorrect because it occurs after a period of heavy drinking or when the usual alcohol intake is reduced. Alcoholic hallucinosis is characterized by hallucinations. Answer B is incorrect because it refers to the headache and gastrointestinal symptoms experienced after drinking alcohol. Sunday morning paralysis refers to radial nerve palsy commonly observed when a stuporous person lies with his arm pressed over a projecting surface; therefore, answer D is incorrect.
Which of the following observations in a 4-year-old suggests the possibility of child abuse?
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Solution
Answer A is correct. “Rainbow” bruises refer to bruises in various stages of healing. Although they are not conclusive proof of physical abuse, they do suggest the possibility. Answer B is incorrect because the 4-year-old might still suck the thumb when going to sleep. The victim of child abuse usually endures painful procedures with little expression of emotion; therefore, answer C is incorrect. Victims of child abuse are usually reluctant to talk to strangers; therefore, answer D is incorrect.
The nurse is assessing a primgravida 12 hours after a Caesarean section. The nurse notes that the client’s fundus is at the umbilicus and is firm. The nurse should:v
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Solution
Answer C is correct. The client’s assessment findings are within normal 12 hours after a Caesarean section; therefore, the nurse should chart the finding. Answer A is incorrect because the assessment does not reveal the presence of bladder distention. Answer B is incorrect because the assessment does not reveal uterine atony. Answer D is incorrect because the client needs to ambulate.
A client scheduled for surgery has a preoperative order for atropine on call. The nurse should tell the client that the medicationwill:
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Solution
Answer B is correct. Atropine is given to dry secretions and lessens the likelihood of aspiration. Answers A, C, and D are inaccurate statements; therefore, they are incorrect.
The physician has ordered Dolophine (methadone) for a client withdrawing from opiates. Which finding is associated with acute methodone toxicity?
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Solution
Answer D is correct. Methodone is an opiod agonist; therefore, it is capable of producing respiratory depression.
A client has returned from having an arteriogram. The nurse should give priority to:
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Solution
Answer B is correct. During an arteriogram, contrast media is injected directly into the artery. The nurse should give priority to assessing the site for bleeding. Answers A, C, and D are incorrect because they do not take priority over assessing the site for bleeding.
Before moving a client up in bed, the nurse lowers the head of the bed. The purpose of lowering the head of the bed is:
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Solution
Answer A is correct. Moving the client up in the bed is easier with the head of the bed lowered because the nurse does not have to work against the force of gravity. Answer B is incorrect because lowering the head of the bed will not prevent wrinkles in the linen. Answer C is incorrect because lowering the head of the bed will not eliminate the need for additional help to move the client. Answer D is incorrect because lowering the head of the bed will not relieve pressure on the client’s sacrum.
The physician has ordered a straight catheterization for a female client. When performing a straight catheterization on a female client, the nurse should:v
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Solution
Answer D is correct. When performing a straight catheterization, the nurse should hold the catheter in place as the bladder empties to prevent it from slipping out. Answer A is incorrect because surgical, not medical, asepsis is used when performing a catheterization. Answer B is incorrect because the catheter should be inserted 2–3 inches. Answer C is incorrect because the straight catheter does not have a balloon for inflation.
The nurse is observing a developmental assessment of an infant. Which of the following is an example of cephalocaudal development?
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Solution
Answer C is correct. Cephalocaudal development refers to head-to-tail (toe) development; therefore, the infant can raise her head before she can sit. Answer A is an example of simple-to-complex development; therefore, it is incorrect. Answer B is an example of proximodistal development; therefore, it is incorrect. Answer D is an example of general-to-specific development; therefore, it is incorrect.
A post-operative client has called the nurse’s station with complaints of pain. The first action by the nurse should be to:
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Solution
Answer D is correct. The nurse should first assess the client to determine the location and character of the pain. Answers A, B, and C are incorrect because they are not the first action that the nurse should take.