A client is admitted to the chemical dependency unit due to cocaine addiction. The client states, “I don’t know why you are all so worried. I am in control. I don’t have a problem.” Which defense mechanism is being utilized?
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Solution
Answer D is correct. The statement reflects the use of denial as a means of coping with the illness. Answers A, B, and C are defense mechanisms not reflected by the statement.
The nurse is discussing nutritional needs with the dietician at the nursing home. Which diet selection indicates a proper diet for healing of a decubitus ulcer?
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Solution
Answer C is correct. These clients need a balanced nutritional diet with protein and vitamin C, making it the most balanced meal plan. Answers A and B both lack protein, which is very important in maintaining a positive nitrogen balance. Answer D has protein but is lacking in vitamins.
A client is immobile. Which nursing intervention would best improve tissue perfusion to prevent skin problems?
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Solution
Answer D is correct. Activity, exercise, and repositioning the client will increase circulation and improve tissue perfusion. Answer A will help to identify problem areas but will not improve the perfusion of the tissue. Answer B should be avoided because it could increase the damage if trauma was present. Answer C should be done to prevent irritation of the skin, but this action does not improve perfusion.
A client with alcoholism has been instructed to increase his intake of thiamine. Which food is highest in thiamine?
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Solution
Answer D is correct. Pork has more thiamine than beef, fish, or chicken, which makes answers A, B, and C incorrect.
Which one of the following assessment findings is within normal expectations for a post-operative craniotomy client?
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Solution
Answer D is correct. A slight elevation in temperature would be expected from surgical intervention and would not be a cause for concern. Answers A, B, and C could indicate a progressing complication, so they are incorrect.
The nurse has inserted an NG tube for enteral feedings. Which assessment result is the best indication that an NG tube is properly placed in the stomach?
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Solution
Answer B is correct. The aspirate of gastric content should be green, brown, clear, or colorless, with a gastric pH between 1 and 5. Answer A would most likely be from the lungs, so it is incorrect. Answers C and D are not as accurate as color and pH for confirming gastric location, so they are incorrect
The nurse is caring for a client with a basilar skull fracture. Fluid is assessed leaking from the ear. What is the nurse’s first action?
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Solution
Answer C is correct. Testing the drainage for glucose could indicate the presence of cerebrospinal fluid, making this the best initial action. The next action would be to notify the physician, as in answer B. Answers A and D would be contraindicated, so they are incorrect.
The LPN/LVN is working on a team that includes an RN and a nursing assistant. The LPN/LVN should be assigned which of the following clients?
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Solution
Answer B is correct. The LPN should be assigned the client requiring a dressing change. This client is the one most correlated to the LPN’s scope of practice. The clients described in answer options A and D are more appropriate to the RN. The nursing assistant should care for the client needing ambulatory assistance as described in answer C because this relates to the nurses assistants standards and practices.
A client with AIDS is admitted to the unit. A family member asks the nurse, “How much longer will it be?” Which response by the nurse is most appropriate?
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Solution
Answer C is correct. The nurse responds appropriately by answering the question honestly and attempting to assess for more information that will allow the person to ventilate feelings. Answer A is an appropriate response but is not as appropriate as C. Answers B and D are nontherapeutic communication techniques.
Which statement by a client who is taking topiramate (Topamax) indicates that the client has understood the nurse’s instruction?
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Solution
Answer B is correct. There is an increased risk for kidney stones with topiramate (Topamax) use, so fluids are an important part of problem prevention. The drug is not required to be taken with meals or at bedtime, so answers A and D are incorrect. Answer C is not required with the use of this medication.