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Extract:


Question 1 of 5

A client with paranoid personality disorder monopolizes group activities with complaints that the staff is out to get him. The nurse should:

Correct Answer: D

Rationale: One of the most therapeutic actions the nurse can take with the paranoid client is to spend time with him but not challenge his delusions. Answer A would challenge his delusions and make him more convinced that he is right, so it is incorrect. Answers B and C would isolate the client and increase his paranoid thinking, so they're incorrect.

Question 2 of 5

The nurse is teaching a group of college students about breast self-examination. A woman asks for the best time to perform the monthly exam. What is the best reply by the nurse?

Correct Answer: B

Rationale: The best time for a breast self-exam (BSE) is a week after a menstrual cycle, when the breasts are no longer swollen and tender due to hormone elevation.

Extract:

The nurse documents and performs which of the following when the patient refuses his medication?


Question 3 of 5

Kardex; physician.

Correct Answer: C

Rationale: Documenting in the medication record and progress notes, and informing the physician, ensures accurate communication.

Extract:

The patient with ascites has a paracentesis and 1500 ml of fluid is removed.


Question 4 of 5

Immediately following the procedure it is most important for the nurse to observe for:

Correct Answer: A

Rationale: A rapid, thready pulse indicates hypovolemia or shock post-paracentesis, a critical complication.

Extract:


Question 5 of 5

The nurse is assessing a client with a history of heart failure. Which of the following findings would indicate worsening heart failure?

Correct Answer: A

Rationale: Weight gain of 2 kg in 24 hours indicates fluid retention, a sign of worsening heart failure due to decreased cardiac output. Normal blood pressure (
B), heart rate (
C), and clear lungs (
D) do not suggest decompensation.

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