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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

The nurse is assessing a six-year-old following a tonsillectomy. Which one of the following signs is an early indication of hemorrhage?

Correct Answer: A

Rationale: Drooling of bright red secretions indicates active bleeding post-tonsillectomy, an early sign of hemorrhage requiring immediate attention.

Question 3 of 5

A client with metastatic cancer of the lung has just been told the prognosis by the oncologist. The nurse hears the client state, "I don't believe the doctor; I think he has me confused with another patient."

Correct Answer: A

Rationale: The client's statement reflects denial, the first stage of Kubler-Ross' model, where patients refuse to accept a terminal prognosis. Anger (
B), depression (
C), and bargaining (
D) involve different emotional responses.

Question 4 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 5 of 5

A male client was involved in a motor vehicle accident earlier in the day. The nurse caring for him on evenings notices that on admission to the hospital, he lost a lot of blood and required multiple blood transfusions. The nurse would anticipate which blood product would be ordered when a large blood loss has occurred?

Correct Answer: A

Rationale: Whole blood is the transfusion component of choice when large volumes of blood need to be replaced. Whole blood contains all blood components that are lost during active bleeding.

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