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Questions 164

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Extract:


Question 1 of 5

The nurse is caring for assigned clients. The nurse should first check the client with

Correct Answer: A

Rationale: Severe pain (9/10) in sickle cell disease indicates a possible vaso-occlusive crisis, a medical emergency requiring immediate assessment. Fever, tachycardia, and hyperglycemia are less urgent.

Question 2 of 5

The nurse is talking with a client recently diagnosed with HIV infection about home and lifestyle alterations. Which of the following statements indicate that the client correctly understands the teaching? Select all that apply.

Correct Answer: A,B,D

Rationale: Avoiding raw foods, not sharing razors, and using latex-free condoms reduce infection and transmission risks. Barrier methods are still needed with HIV-positive partners to prevent superinfection.

Question 3 of 5

The nurse in the mental health unit observes a client hitting the wall repeatedly with the hands after an upsetting family therapy session. The nurse should recognize that the client is exhibiting which of the following defense mechanisms?

Correct Answer: B

Rationale: Defense mechanisms are unconscious mental processes used to protect individuals from uncomfortable thoughts, internal conflicts, and external stresses. Defense mechanisms may be therapeutic to clients with anxiety. However, with excessive use, defense mechanisms may become notherapeutic because they involve a degree of self-deception and reality distortion that can result in poor interpersonal relationships, irrational behavior, and decreased productivity.

Question 4 of 5

A 14-year-old client confides to the school nurse that she is pregnant, likely in the second trimester, and has not had prenatal care. Which of the following topics should the nurse discuss with the client at this time? Select all that apply.

Correct Answer: A,B,C,D,E

Rationale: All topics are critical: adoption planning, emotional response, support systems, nutrition/substance use, and education planning address the client’s immediate and long-term needs in a sensitive, holistic manner.

Question 5 of 5

Which of the following drugs should the nurse anticipate administering to a client before they are to receive electroconvulsive therapy?

Correct Answer: C

Rationale: Succinylcholine (Anectine). Succinylcholine is given intravenously to promote skeletal muscle relaxation.

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