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Questions 158

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Question 1 of 5

A 28-year-old client performs a long, involved ritual in getting up and preparing for the day. He became unable to get to his job before noon. His family, in desperation, has admitted him to the hospital's psychiatric unit. On the unit, he is always late for breakfast, which is served at 8 am. The nurse identifies that the best approach to this problem is to:

Correct Answer: C

Rationale:
To interfere with the ritual will increase anxiety. Arranging the schedule to allow completion of the ritual before essential activities like breakfast accommodates the client's needs while addressing the issue.

Question 2 of 5

At 30 weeks' gestation, a client is admitted to the unit in premature labor. Her physician orders that an IV be started with 500 mL D5W mixed with 150 mg of ritodrine stat. The RN prepares the IV solution with the medication. The RN knows that clients receiving the medication ritodrine IV should be observed closely for which one of the following side effects:

Correct Answer: C

Rationale: Ritodrine is a sympathomimetic β2-adrenergic agonist that can cause vasodilation, leading to hypotension. The body compensates by increasing heart rate, resulting in tachycardia.

Question 3 of 5

A psychiatric nurse is providing an orientation to a new staff nurse. She reminds the nurse that psychiatrists often use categories of medications and that it is important that she recall that some categories of medications have synonyms. Another name used to describe minor tranquilizers is which of the following?

Correct Answer: C

Rationale: Antianxiety medications are also known as minor tranquilizers.

Question 4 of 5

At 12 hours postvaginal delivery, a female client is without complications. Which of the following assessment findings would warrant further nursing interventions?

Correct Answer: B

Rationale: Bradycardia of 50-70 bpm may be considered normal postpartally because the heart compensates for the decreased resistance in the pelvis. The uterus is displaced from the midline by a full bladder. This condition could lead to a boggy uterus and increased risk of postpartal hemorrhage; therefore, the bladder should be kept empty. Re-establishment of normal bowel function is delayed into the first postpartum week. A postpartum woman's oral temperature may go as high as 100.4°F within 24 hours of delivery resulting from muscular exertion, dehydration, and hormonal changes.

Question 5 of 5

A 5-year-old child has suffered second-degree thermal burns over 30% of her body. Forty-eight hours after the burn injury, the nurse must begin to monitor the child for which one of the following complications?

Correct Answer: B

Rationale: Fluid volume deficit resulting from fluid shifts to the interstitial spaces occurs in the first 48 hours. Forty-eight hours to 72 hours after the burn injury and fluid resuscitation, capillary permeability is restored and fluid requirements decrease. Interstitial fluid returns rapidly to the vascular compartment, and the nurse must monitor the child for signs and symptoms of hypervolemia. Increased cardiac output results as fluids shift back to the vascular compartment. Hypertension is the result of hypervolemia.

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