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If your patient is acutely psychotic, which of the following independent nursing interventions would not be appropriate?
A. Conveying calmness with one on one interaction
B. Recognizing and dealing with your own feelings to prevent escalation of thepatient’s anxiety level
C. Encourage client participation in group therapy
D. Listen and identify causes of their behavior
Which of the following syndromes associated with incomplete lesions of the spinal cord is a result of damage to one-half of the spinal cord?
A. Brown-Séquard syndrome
B. posterior cord syndrome
C. central cord syndrome
D. cauda equina syndrome
A client receiving preoperative instructions asks questions repeatedly about when to stop eating the night before the procedure. The nurse tries torefocus the client. The nurse notes that the client is frequently startled by noises in the hall. Assessment reveals rapid speech, trembling hands, tachypnea, tachycardia, and elevated blood pressure. The client admits to feeling nervous and having trouble sleeping. Based on the assessment, the nurse documents that the client has:
A. mild anxiety.
B. moderate anxiety.
C. severe anxiety.
D. a panic attack.
A 64 year-old Alzheimer’s patient has exhibited excessive cognitive decline resulting in harmful behaviors. The physician orders restraints to be placed on the patient. Which of the following is the appropriate procedure?
A. Secure the restraints to the bed rails on all extremities.
B. Notify the physician that restraints have been placed properly.
C. Communicate with the patient and family the need for restraints.
D. Position the head of the bed at a 45 degree angle.
A client was involved in a motor vehicle accident in which the seat belt was not worn. The client is exhibiting crepitus, decreased breath sounds on the left, complains of shortness of breath, and has a respiratory rate of 34/min. Which of the following assessment findings should concern the nurse the most?
A. temperature of 102° F and a productive cough
B. arterial blood gases (ABGs) with a PaO2 of 92 and PaCO2 of 40 mmHg
C. trachea deviating to the right
D. barrel-chested appearance
Metformin (Glucophage) is administered to clients with type II diabetes mellitus. Metformin is an example of:
A. an antihyperglycemic agent.
B. a hypoglycemic agent.
C. an insulin analogue.
D. a pancreatic alpha cell stimulant.
An nurse is instructing a patient on the order of sensations with the application of an ice water bath for a swollen right ankle. Which of the following is the correct order of sensations experienced with an ice water bath?
A. cold, burning, aching, and numbness
B. burning, aching, cold, and numbness
C. aching, cold, burning and numbness
D. cold, aching, burning and numbness
A 20-year-old male client had a diving accident with subsequent paraplegia. He says to thenurse, “No woman will ever want to marry me now.” Which of the following responses bythe nurse is most therapeutic?
A. “Don’t worry. Maybe you’ll meet a paraplegic woman.”
B. “There is someone for everyone in this world.”
C. “You are still an attractive man, even though you can’t walk.”
D. “Tell me more about your feelings on this issue.”
A patient has recently been prescribed Zidovudine (Retrovir). The patient has AIDS. Whichof the following side effects should the patient specifically watch out for?
A. Weakness and SOB
B. Fever and anemia
C. Hypertension and SOB
D. Fever and hypertension
A client reports that someone is in the room and trying to kill him. The nurse’s best response is:
A. “No one is in your room. Let’s get you more medicine.”
B. “I do not see anyone, but you seem to be very frightened.”
C. “No one can hurt you here.”
D. “Just tell the person to go away.”