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| Section | Weight | Objectives |
|---|---|---|
| Safety and Infection Control | 10-16% | - Safety and Infection Control
|
| Health Promotion and Maintenance | 6-12% | - Health Promotion and Maintenance
|
| Physiological Adaptation | 11-17% | - Physiological Adaptation
|
| Reduction of Risk Potential | 9-15% | - Reduction of Risk Potential
|
| Management of Care | 15-21% | - Management of Care
|
| Pharmacological and Parenteral Therapies | 13-19% | - Pharmacological and Parenteral Therapies
|
| Psychosocial Integrity | 6-12% | - Psychosocial Integrity
|
| Basic Care and Comfort | 6-12% | - Basic Care and Comfort
|
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NEW QUESTION # 122
At 38 weeks' gestation, a client is in active labor. She is using her Lamaze breathing techniques. The RN is coaching her breathing and encouraging her to relax and work with her contractions. Which one of the following complaints by the client will alert the RN that she is beginning to hyperventilate with her breathing?
Answer: D
Explanation:
Explanation
(A) Cold is not a symptom of hyperventilation. This could be due to the temperature of the room. (B) Backache is not a symptom of hyperventilation. This is probably due to the gravid uterus and its effect on the back muscles, or it may be due to the client's position in bed. (C) Dizziness is the first symptom of hyperventilation. It occurs because the body is eliminating too much CO2. (D) Nausea is not a symptom of hyperventilation. It could be a symptom of pain.
NEW QUESTION # 123
Nursing care for the parents of a child with a congenital heart defect would include:
Answer: D
Explanation:
Explanation
(A) It is important to discuss with parents the need to treat the child as they would any other children, but they must be truthful and honest with the child about the heart defect. As the child grows older, explanations can go into greater depth. (B) Parents of children with congenital heart defects go through a grieving process over the loss of their "healthy" child. The nurse needs to recognize these feelings and give the parents a role in the child's care when they are ready. (C) Anger and resentment are normal feelings that must be dealt with appropriately. (D) Parents may go through a second grieving process after the repair of the cardiac defect.
During this grieving period, they mourn the loss of the "defective" child who now may be essentially
"normal."
NEW QUESTION # 124
In working with a manipulative client, which of the following nursing interventions would be most appropriate?
Answer: C
Explanation:
Explanation
(A) This answer is incorrect. Bargaining is a manipulative act, which the nurse could expect from the client.
(B) This answer is incorrect. Confrontation is an effective nursing strategy with manipulative behavior.
Redirection is appropriate for the client who is out of touch with reality. (C) This answer is correct.
Manipulative clients must abide by consistent rules. (D) This answer is incorrect. Manipulation is kept at a minimum if the same staff person is assigned to the client. Often the client will attempt to play staff persons against each other.
NEW QUESTION # 125
The physician orders haloperidol 5 mg IM stat for a client and tells the nurse that the dose can be repeated in
1-2 hours if needed. The most likely rationale for this order is:
Answer: B
Explanation:
Section: Questions Set G
Explanation:
(A) If the client could think logically, he would not be paranoid. In fact, he is probably suspicious of the staff, too. Newly admitted clients frequently experience high levels of anxiety, which can contribute to delusions. (B) The goal of pharmacological intervention is to calm the client and assist with reality-based thinking, not to sedate him. (C) Haloperidol is a neuroleptic and antipsychotic drug, not a minor tranquilizer. (D) Haloperidol is a high-potency neuroleptic and first-line choice for rapid neuroleptization, with low potential for sedation.
NEW QUESTION # 126
A client was not using his seat belt when involved in a car accident. He fractured ribs 5, 6, and 7 on the left and developed a left pneumothorax. Assessment findings include:
Answer: D
Explanation:
Explanation
(A) Crackles are caused by air moving through moisture in the small airways and occur with pulmonary edema. Paradoxical chest wall movement occurs with flail chest when a segment of the thorax moves outward on inspiration and inward on expiration. (B) Decreased breath sounds occur when a lung is collapsed or partially collapsed. Chest pain with movement occurs with rib fractures. (C) Rhonchi are caused by air moving through large fluid-filled airways. Frothy sputum may occur with pulmonary edema. (D) Wheezing is caused by fluid in large airways already narrowed by mucus or bronchospasm. Dry cough could indicate a cardiac problem.
NEW QUESTION # 127
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