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Questions 158

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Question 1 of 5

A 22-year-old single woman was admitted to the psychiatric hospital by her mother, who reported bizarre behavior. Except for going to work, she spends all her time in her room and expresses concern over neighbors spying on her. She has fears of the telephone being 'bugged.' Her diagnosis is schizophrenia. One nurse per shift is assigned to work with the client. The primary reason for this plan would be to:

Correct Answer: B

Rationale: The client is suspicious and needs help to develop trust, which is basic to her improvement. Consistent nursing assignment fosters a therapeutic relationship.

Question 2 of 5

A client with a history of a hiatal hernia is being discharged. The nurse should teach the client to:

Correct Answer: C

Rationale: Carbonated beverages increase gastric pressure, worsening hiatal hernia symptoms. Sleeping upright, small meals, and avoiding lying down post-meals are also recommended.

Question 3 of 5

A five-year-old is admitted to the unit following a tonsillectomy. Which of the following would indicate a complication of the surgery?

Correct Answer: D

Rationale: Constant swallowing post-tonsillectomy suggests bleeding, as the child may be swallowing blood from the surgical site, a serious complication requiring immediate attention. Decreased appetite and low-grade fever are expected, and chest congestion is unrelated.

Question 4 of 5

A 45-year-old client diagnosed with major depression is scheduled for electroconvulsive therapy (ECT) in the morning. Which of the following medications are routinely administered either before or during ECT?

Correct Answer: B

Rationale: Thioridazine (an antipsychotic drug), lithium (an antimanic drug), and benztropine (an antiparkinsonism agent) are generally administered to treat schizophrenic and bipolar disorders. Atropine (a cholinergic blocker), sodium brevitol (a short-acting anesthetic), and succinylcholine (a neuromuscular blocker) are administered either before or during ECT to counteract bradycardia and to provide anesthesia and total muscle relaxation. These are electrolyte substances administered to correct fluid and electrolyte imbalances in the body. Carbamazepine (an anticonvulsant), haloperidol (an antipsychotic), and trihexyphenidyl (an antiparkinsonism agent) are usually administered in psychiatric settings to control problems associated with psychotic behavior.

Question 5 of 5

Goal setting for a client with Meniere's disease should include which of the following?

Correct Answer: B

Rationale: Although not contraindicated, initially ambulation may be difficult because of vertigo and is recommended only with assistance. Vertigo resulting in balance problems is one of the most common manifestations of Meniere's disease. Adequate nutrition is important, but the emphasis in Meniere's disease is not the number of meals per day but a decrease in intake of sodium. Infection is not an anticipated problem.

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