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| Section | Weight | Objectives |
|---|---|---|
| Psychosocial Integrity | 6–12% | |
| Health Promotion and Maintenance | 6–12% | |
| Safe and Effective Care Environment | 17–33% | - Safety and Infection Control - Management of Care |
| Physiological Integrity | 43–67% | - Basic Care and Comfort - Physiological Adaptation - Pharmacological and Parenteral Therapies - Reduction of Risk Potential |
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NEW QUESTION # 529
Which of the following nursing care goals has the highest priority for a child with epiglottitis?
Answer: D
Explanation:
Explanation
(A) Of these four goals, maintenance of a calm, quiet atmosphere to reduce anxiety and to allow for rest is the most important. (B) Although nutrition is important, the child needs fluids to maintain fluid and electrolyte balance more than solid foods. In addition, the child may not be able to swallow solid foods owing to epiglottic swelling. (C) This goal is unrealistic because fever is a common symptom of the infection associated with epiglottitis. (D) If overexerted, the child will need more O2 and energy than available, and these requirements may exacerbate the condition.
NEW QUESTION # 530
The mother of a 7-year-old mental health center client reports that the client has refused to attend gymnastics for the past 2 weeks. Prior to that time, the child liked going to this class and was attending 3 times a week. In talking with the client, the nurse would:
Answer: D
Explanation:
Explanation/Reference:
Explanation:
(A) The child has not said that she dislikes gymnastics. (B) The nurse will be able to obtain information on what events occurred at gymnastics prior to her refusal to attend. The nurse will also gain information about the child's perception of the problem. (C) The child has not said she is afraid to go to gymnastics. (D) False reassurance is inappropriate.
NEW QUESTION # 531
The nurse would be sure to instruct a client on the signs and symptoms of an eye infection and hemorrhage. These signs and symptoms would include:
Answer: D
Explanation:
(A) Although blurred vision may occur, dizziness would not be associated with an infection or hemorrhage. (B) Eye pain is a symptom of hemorrhage within the eye, and itching is associated with infection. (C) Nausea and headache would not be usual symptoms of eye hemorrhage or infection. (D) Some eye discharge might be anticipated if an infection is present; hemoptysis would not.
NEW QUESTION # 532
A male client is being treated in the burn unit for thirddegree burns on his head, neck, and upper chest received in the last 24 hours. The nurse is evaluating the effectiveness of fluid resuscitation. Which of the following indicates effective fluid balance?
Answer: D
Explanation:
Explanation
(A) A weight gain of 10 lb represents a state of overhydration. (B) He is losing fluids through insensible losses; a urine output equal to his intake indicates that he is receiving too little fluids. (C) A urine output greater than his intake indicates that he is receiving adequate fluid resuscitation to account for urinary and insensible losses. (D) A blood pressure of 94/62 indicates a state of underhydration and inadequate circulatory volume.
NEW QUESTION # 533
A depressed client is seen at the mental health center for follow-up after an attempted suicide 1 week ago. She has taken phenelzine sulfate (Nardil), a monoamine oxidase
(MAO) inhibitor, for 7 straight days. She states that she is not feeling any better. The nurse explains that the drug must accumulate to an effective level before symptoms are totally relieved. Symptom relief is expected to occur within:
Answer: C
Explanation:
(A) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication.
(B) This answer is correct. Because MAO inhibitors are slow to act, it takes 2-4 weeks before improvement of symptoms is noted.
(C) This answer is incorrect. It can take up to 1 month for therapeutic effect of the medication.
(D) This answer is incorrect. Therapeutic effects of the medication are noted within 1 month of drug therapy.
NEW QUESTION # 534
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