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Questions 158

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Question 1 of 5

The nurse is planning a reality orientation program for a group of clients with organic brain syndrome at the mental health center. Props that could be used for this program are:

Correct Answer: B

Rationale: This answer is incorrect. Current magazines would be appropriate. This answer is correct. Maps of the state and town and posters that depict current events in the area are appropriate props. This answer is incorrect. Kittens would be appropriate for pet therapy, not reality therapy. This answer is incorrect. Biographies depict a past, not a present, orientation.

Question 2 of 5

Which statement is true regarding a patient with a Sengstaken-Blakemore tube?

Correct Answer: D

Rationale: A Sengstaken-Blakemore tube is used for esophageal variceal bleeding. Scissors must be kept at the bedside to cut the tube in case of airway obstruction from balloon migration. The gastric balloon (not esophageal) controls bleeding the tube has three lumens and esophageal balloon pressure is typically 20-25 mmHg.

Question 3 of 5

In acute episodes of mania, lithium is effective in 12 weeks, but it may take up to 4 weeks, or even a few months, to treat symptoms fully. Sometimes an antipsychotic agent is prescribed during the first few days or weeks of an acute episode to manage severe behavioral excitement and acute psychotic symptoms. In addition to the lithium, which one of the following medications might the physician prescribe?

Correct Answer: B

Rationale: Haloperidol is an antipsychotic medication and may be used until the lithium takes effect.

Question 4 of 5

A 2-year-old child is recovering from surgery. Considering growth and development according to Erikson, the nurse identifies which of the following play activities as most appropriate?

Correct Answer: A

Rationale: A 2-year-old child is in the stage of autonomy, according to Erikson. Assembling a puzzle with large pieces enables her to 'do it herself.' A wheelchair ride would probably be fun, but it is not directed toward helping the child to achieve autonomy. Listening to a story may be fun and educational, but it is not directed toward helping the child to achieve autonomy. Watching television may be a favorite activity, but it does not foster autonomy.

Question 5 of 5

A male client is experiencing auditory hallucinations. His nurse enters the room and he tells her that his mother is talking to him, and he will take his medicine after she leaves. The nurse looks around the room and sees that she and the client are the only ones in the room. The nurse's most therapeutic response will be:

Correct Answer: A

Rationale: This response uses the principle of reality orientation by the nurse telling the client that he or she does not see anything, but it does recognize his feelings.

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