A client with mania is unable to finish her dinner. To help her maintain sufficient nourishment, the nurse should:
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Solution
Answer A is correct. The client with mania is seldom sitting long enough to eat and burns many calories for energy. Answer B is incorrect because the client should be treated just as other clients are. Answer C is incorrect because small meals are not correct as an option for this client. Also, in answer D, allowing her into the kitchen gives her privileges that other clients do not have and should not be allowed.
The primary physiological alteration in the development of asthma is:
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Solution
Answer D is correct. Asthma is the presence of bronchiolar spasms. This spasm can be brought on by allergies or anxiety. Answer A is incorrect because the primary physiological alteration is not inflammation. Answer B is incorrect because there the production is abnormally viscous mucus, not a primary alteration. Answer C is incorrect because infection is not primary to asthma.
During the assessment of a laboring client, the nurse notes that the FHT are loudest in the upper-right quadrant. The infant is most likely in which position?
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Solution
Answer A is correct. The fetal heart tones are heard in the upper abdomen. The positions in answers B, C, and D would lead to the presence of fetal heart tones being detected in the lower abdomen. In answer C, the sacrum is the back. This would lead to fetal heart tones being heard above the umbilicus, but on the right side, not the left
A client with a history of abusing barbiturates abruptly stops drug use. The nurse should give priority to assessing the client for:
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Solution
Answer B is correct. Barbiturates create a sedative effect. When the client stops taking barbiturates, he will experience tachycardia, diarrhea, and tachpnea. Answer A is incorrect because depression and suicidal ideation go along with barbiturate use. Muscle cramps and abdominal pain are vague symptoms; therefore, answer C is incorrect. Tachycardia is associated with stopping barbiturates, but euphoria is not; thus, answer D is incorrect.
The client is admitted to the chemical dependence unit with an order for continuous observation. The nurse is aware that the doctor has ordered continuous observation because:
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Solution
Answer B is correct. Hallucinogenic drugs can cause hallucinations. Continuous observation is ordered to prevent the client from harming himself during withdrawal. Answer A is incorrect because hallucinogenic drugs don’t create both stimulant and depressant effects. Answer C is incorrect because these drugs do not produce severe respiratory depression. Answer D is incorrect because these drugs produce psychological dependence rather than physical dependence.
A client with acute pancreatitis is experiencing severe abdominal pain. Which of the following orders should the nurse question?
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Solution
Answer D is correct. Morphine is contraindicated in clients with gallbladder disease and pancreatitis because morphine causes spasms of the Sphenter of Oddi. Meperidine, Mylanta, and Cimetadine can be taken by the client with pancreatitis, so answers A, B, and C are incorrect.
Which of the following instructions should be included in the teaching for the client with rheumatoid arthritis?
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Solution
Answer B is correct. Clients with rheumatoid arthritis should exercise, but not to the point of pain and not when inflammation is present, so answer A is incorrect. Antiinflammatory drugs should be taken with meals because they cause stomach upset. Alternating heat and cold is not necessary, so answer C is incorrect. Warm, moist soaks are useful to decrease pain. Weight-bearing activities such as walking are useful, so answer D is incorrect.
A client is admitted with complaints of chest pain. Which of the following drug orders should the nurse question?
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Solution
Answer B is correct. Clients with chest pain can be treated with nitroglycerin, a beta blocker such as propanolol, or Varapamil, so answers A, C, and D are incorrect. There is no indication for an antibiotic such as ampicillin.
The client with varicella will most likely have an order for which category of medication?
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Solution
Answer C is correct. Varicella is chicken pox. This herpes virus is treated with antiviral medications. The client is not treated with antibiotics or anticoagulants, so answers A and D are incorrect. The client might have a fever before the rash appears, but when the rash appears, the temperature is usually gone; thus, answer B is incorrect.
A gravida III para II is admitted to the labor unit. Vaginal exam reveals that the client’s cervix is 8cm dilated withcomplete effacement. The priority nursing diagnosis at this time is:
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Solution
Answer A is correct. Transition is the time during labor when the client loses concentration due to intense contractions. Potential for injury related to precipitate delivery has nothing to do with the dilation of the cervix, so answer B is incorrect. There is no data to indicate that the client has had anesthesia or fluid volume deficit, so answers C and D are incorrect.