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Questions 158

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Question 1 of 5

A female baby was born with talipes equinovarus. Her mother has requested that the nurse assigned to the baby come to her room to discuss the baby's condition. The nurse knows that the pediatrician has discussed the baby's condition with her mother and that an orthopedist has been consulted but has not yet seen the baby. What should the nurse do first?

Correct Answer: B

Rationale: The nurse should call the orthopedist after assessing the mother's knowledge. The nurse must first assess the knowledge of the parent before attempting any explanation. The nurse should assess the mother's knowledge of the baby's condition as the first priority. This answer is correct, but the priority is B.

Question 2 of 5

The nurse is teaching a client with type 1 diabetes about insulin administration. Which statement by the client indicates a need for further teaching?

Correct Answer: D

Rationale: In type 1 diabetes, insulin requirements may change during illness, and skipping doses without medical guidance can lead to ketoacidosis. The other statements are correct: rotating sites prevents lipodystrophy, checking blood sugar guides dosing, and mixing insulins is allowed.

Question 3 of 5

A male client has asthma and his physician has prescribed beclomethasone (Vanceril) 3 puffs tid in addition to his other medications. After taking his beclomethasone, the client should be instructed to:

Correct Answer: B

Rationale: Drinking water or gargling after using a steroid inhaler like beclomethasone prevents oral candidal infections, a common side effect.

Question 4 of 5

A client with a history of hepatitis C is admitted with complaints of fatigue. The nurse should expect the client to have:

Correct Answer: A

Rationale: Hepatitis C causes liver inflammation, leading to elevated liver enzymes (e.g., AST, ALT), a common finding reflecting hepatic damage.

Question 5 of 5

A 14-year-old teenager is demonstrating behavior indicative of an obsessive-compulsive disorder. She is obsessed with her appearance. She will not leave her room until her hair, clothes, and makeup are perfect. She always dresses immaculately. Recently, she expressed disgust over her appearance after she gained 5 lb. After observing a marked weight loss over a 2-week period, her mother suspects that she is experiencing bulimia. She eats everything on her plate, then runs to the bathroom. In interviewing the teenager, she discusses in great detail all of the events leading to her bulimia, but not her feelings. What defense mechanism is she using?

Correct Answer: B

Rationale: Dissociation is separating a group of mental processes from consciousness or identity, such as multiple personalities. That is not evident in this situation. Intellectualization is excessive use of reasoning, logic, or words usually without experiencing associated feelings. This is the defense mechanism that this client is using. Rationalization is giving a socially acceptable reason for behavior rather than the actual reason. She is discussing events, not reasons. Displacement is a shift of emotion associated with an anxiety-producing person, object, or situation to a less threatening object.

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