question of the week

Question of the week for 07.19.10

A client is being discharged with a prescription for chlorpromazine (Thorazine). Before the client leaves for home, which finding should a nurse teach the client to report within 24 hours?

1. Change in libido, breast enlargement
2. Sore throat, fever
3. Abdominal pain, nausea
4. Dyspnea, nasal congestion

question of the week

Question of the week for 06.28.10

During assessment of clients, a nurse should be informed about cultural issues related to the client's background for what reason?

1. Normal patterns of behavior may be labeled as deviant, immoral, or insane
2. The meaning of the client's behavior can be derived from conventional wisdom
3. Personal values will guide the interaction between persons from two cultures
4. The nurse should rely on any knowledge of different developmental mental stages

question of the week

Question of the week for 06.21.10

A nurse is to present information about Chinese folk medicine to a group of student nurses. Based on this cultural belief system, the nurse would explain that illness is attributed to which focus?

1. Yang, the positive force that represents light, warmth, and fullness
2. Yin, the negative force that represents darkness, cold, and emptiness
3. The use of improper hot foods, herbs and plants
4. A failure to keep life in balance with nature and others

question of the week

Question of the week for 06.14.10

A nurse is teaching a client about the difference between tardive dyskinesia (TD) and neuroleptic malignant syndrome (NMS). Which statement is true about tardive dyskinesia?

1. TD develops within hours or years of continued antipsychotic drug use in people under 20 and over 30
2. It can occur in clients taking antipsychotic drugs longer than two years
3. TD occurs within minutes of the first dose of antipsychotic drugs and is reversible
4. TD can easily be treated with anticholinergic drugs

question of the week

Question of the week for 06.07.10

Which assessment findings require immediate discontinuance of an antipsychotic medication?

1. Involuntary rhythmic stereotypic movements and tongue protrusion
2. Cheek puffing and involuntary movements of extremities and trunk
3. Agitation and constant state of motion
4. Hyperpyrexia and severe muscle rigidity

question of the week

Question of the week for 06.01.10

A client has received the first dose of fluphenazine (Prolixin) two hours ago. The client suddenly experiences torticollis and involuntary spastic muscle movement. In addition to administering the ordered anticholinergic drug, what other action should a nurse implement?

1. Have respiratory support equipment available
2. Immediately place the client in a seclusion room
3. Assess the client for anxiety and agitation
4. Administer prn dose of an IM antipsychotic medication

question of the week

Question of the week for 05.24.10

A client has been taking alprazolam (Xanax) for three days. Nursing assessment should reveal which expected effect of the drug?

1. Tranquilization and numbing of emotions
2. Sedation and analgesia
3. Relief of insomnia and phobias
4. Diminished tachycardia and tremors associated with anxiety

question of the week

Question of the week for 05.17.10

Which finding contraindicates the use of haloperidol (Haldol) so that a nurse should withhold the dose?

1. Drowsiness, lethargy, and inactivity
2. Dry mouth, nasal congestion, and blurred vision
3. Rash, blood dyscrasias, and severe depression
4. Hyperglycemia, weight gain, and edema

question of the week

Question of the week for 05.10.10

What is a postprocedure nursing intervention for electroconvulsive therapy (ECT)?

1. Offer frequent sips of clear liquids
2. Permit the client to sleep for four to six hours
3. Remain with client until oriented to time, place and person
4. Expect long-term memory loss for a few hours

question of the week

Question of the week for 05.03.10

Which of these client's behaviors would indicate that the nurse-client relationship has passed from the orientation phase to the working phase?

1. Has revitalized a relationship with the family to help cope with the death of a daughter
2. Recognized regressive behaviors as a defense mechanism
3. Expressed a desire to be cared for and pampered
4. Identified feelings about situations and expresses them appropriately

question of the week

Question of the week for 04.26.10

Privacy and confidentiality of client information is legally protected. In which of these situations would a nurse make an exception to this practice?

1. When a family member offers information about their loved one
2. When the client threatens self-harm or harm to others
3. When the provider decides the family has a right to know the client's diagnosis
4. When a visitor insists that the visitor has been given permission by the client

question of the week

Question of the week for 04.19.10

In a psychiatric unit setting, a nurse should limit touch or physical contact used with clients to handshaking for what reason?

1. Some clients misconstrue hugs as an invitation to sexual advances
2. Handshaking keeps the gesture on a professional level
3. Refusal to touch a client denotes lack of concern
4. Inappropriate touch often results in charges of assault and battery

question of the week

Question of the week for 04.12.10

During the evaluation phase for a client, the nurse should focus on which aspect?

1. Findings of physical and psychosocial stressors of the client and in the family
2. The client's status, progress toward goal achievement, and ongoing reevaluation
3. Setting short and long-term goals to insure continuity of care from hospital to home
4. Select interventions that are measurable and achievable within selected timeframes

question of the week

Question of the week for 04.05.10

Which statement made by a client indicates to a nurse that the client may have a thought disorder?

1. "I'm so angry about this. Wait until my partner hears about this."
2. "I'm a little confused. What time is it?"
3. "I can't find my 'mesmer' shoes. Have you seen them?"
4. "I'm fine. It's my daughter who has the problem."

question of the week

Question of the week for 03.29.10

A nurse is assessing the mental status of a client admitted with possible organic brain disorder. Which of these questions would best assess the functioning of the client's recent memory?

1. "Name the year." "What season is this?" (pause for answer after each question)
2. "Subtract the number seven from 100 and then subtract seven from that." (pause for answer) "Now continue to subtract seven from the new number."
3. "I am going to say the names of three things and I want you to repeat them after me: blue, ball, pen."
4. "What is this on my wrist?" (point to your watch) Then ask, "What is the purpose of it?"

question of the week

Question of the week for 03.22.10

A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to a nurse that the client is using the mechanism of "suppression"?

1. "I don't remember anything about what happened to me."
2. "I'd rather not talk about it right now."
3. "It's all the other guy's fault! He was going too fast."
4. "My mother is heartbroken about this."

question of the week

Question of the week for 03.15.10

A nurse is teaching a client about the healthy use of ego defense mechanisms. An appropriate goal for this client should be which of these?

1. Reduce fear and protect self-esteem
2. Minimize anxiety and delay apprehension
3. Avoid conflict and leave unpleasant situations
4. Increase independence and communicate more often

question of the week

Question of the week for 03.08.10

A nurse is providing home care for a client with chronic bilateral heart failure. Which nursing diagnosis should have priority in planning care?

1. Impaired skin integrity related to dependent edema
2. Activity intolerance related to an imbalance in oxygen supply and demand
3. Constipation related to immobility from challenges with breathing
4. Risk for infection related to ineffective mobilization of secretions

question of the week

Question of the week for 03.01.10

A client has returned to the unit after having had a renal biopsy. Which of these nursing interventions is appropriate?

1. Ambulate the client four hours after procedure
2. Maintain client on NPO status for 24 hours
3. Monitor vital signs more frequently
4. Change the dressing every eight hours

question of the week

Question of the week for 02.22.10

To prepare a client for an Intravenous Pyelogram (IVP) a nurse should include which action?

1. Instruct the client to maintain a regular diet the day prior to the examination
2. Restrict the client's fluid intake four hours prior to the examination
3. Administer a laxative to the client the evening before and an enema the morning of
4. I nform the client that only one x-ray of the abdomen is necessary