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Questions 176

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Extract:


Question 1 of 5

A client continually repeats phrases that others have just said. The nurse recognizes this behavior as

Correct Answer: C

Rationale: Echolalia is repeating words or phrases heard before, often seen in certain psychiatric or developmental conditions.

Question 2 of 5

A client with metastatic esophageal cancer says, 'I don't want to be kept alive being fed by a tube.' What are the most appropriate ways for the nurse to ensure that this information is available to all who may need it for future decision-making? Select all that apply.

Correct Answer: A, B, C

Rationale: Documenting in the EHR (
A), discussing with the proxy (
B), and completing an advance directive (
C) ensure the client's wishes are communicated. Informed consent (
D) is irrelevant, and DNR (E) is not indicated.

Question 3 of 5

A client with borderline personality disorder says to the nurse, 'You're the only one I trust around here. The others don't know what they are doing and they don't care about anyone except themselves. I only want to talk with you.' What is the priority nursing action?

Correct Answer: D

Rationale: Reinforcing boundaries (
D) addresses splitting behavior and maintains therapeutic relationships. Rotating staff (
A), assigning the preferred nurse (
B), or reassuring competence (
C) may reinforce manipulation.

Question 4 of 5

Postoperative orders for a client undergoing a mitral valve replacement include monitoring pulmonary artery pressure together with pulmonary capillary wedge pressure with a pulmonary artery catheter. The purpose of these actions by the nurse is to assess

Correct Answer: B

Rationale: Left ventricular end-diastolic pressure. The pulmonary capillary wedge pressure is reflective of left ventricular end-diastolic pressure, assessing the heart's ability to pump effectively.

Question 5 of 5

The nurse is teaching about nonsteroidal anti-inflammatory drugs (NSAIDs) to a group of arthritic clients. To minimize the side effects, the nurse should emphasize which of the following actions?

Correct Answer: B

Rationale: Taking the medication 1 hour before or 2 hours after meals. Taking the medication 1 hour before or 2 hours after meals will result in a more rapid effect.

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