A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The client fears for her life. A staff nurse asks, "Why doesn't she just leave him?" Which is the nursing supervisor's most appropriate response? - ANS "These clients are paralyzed into action by a co...
A client who is in a severely abusive relationship is admitted to a psychiatric inpatient unit. The
client fears for her life. A staff nurse asks, "Why doesn't she just leave him?" Which is the
nursing supervisor's most appropriate response? - ANS "These clients are paralyzed into
action by a combination of physical threats and a sense of powerlessness."
Your patient is 12-hours post ORIF right ankle. The patient is asking for a breakthrough dose of
analgesia. The pain-medication orders are written as a combination of an opioid analgesic and a
nonsteroidal anti-inflammatory drug (NSAID) given together. What is the primary rationale for
administering pain medication in this manner? - ANS To achieve better pain control than with
one medication alone.
A client diagnosed with obsessive-compulsive disorder states, "I really think my future will
improve because of my successful treatment choices. I'm going to make my life better." Which
guiding principle of recovery has assisted this client? - ANS Recovery emerges from hope
A client states, "My illness is so devastating, I feel like my life is on hold." The nurse recognizes
that this client is in which stage of the Psychological Recovery Model as described by Andersen
and associates? - ANS Moratorium
A female client on an inpatient unit enters the common area for visiting hours dressed in a
see-through blouse. Which intervention should be a nurse's first priority? - ANS Lead the client
back to her room and assist her with a change of clothing.
A nurse is assessing a client diagnosed with sexual masochistic disorder. What would
differentiate this paraphilic disorder from sexual sadistic disorder? - ANS Masochistic acts can
be performed alone, whereas sadistic acts must have a consenting or non-consenting partner.
A client was recently admitted to the inpatient unit after a suicide attempt. He has been placed
on a tricyclic antidepressant. In terms of medication, what steps should be taken to maintain the
client's safety when he is discharged? - ANS Provide a 1-week supply of medication, with
refills authorized only after he visits his provider.
You are creating a nursing care plan for a patient with a primary diagnosis of cellulitis and a
secondary diagnosis of chronic pain. What common trait of patients who live with chronic pain
, should inform your care planning? - ANS They can experience acute pain in addition to
chronic pain.
Your patient has just returned from the post anesthetic care unit (PACU) following left tibia open
reduction internal fixation (ORIF). The patient is complaining of pain, and you are preparing to
administer the patients first scheduled dose of hydromorphone (Dilaudid). Prior to administering
the drug, you would prioritize which of the following assessments? - ANS The patients allergy
status
Your patient is receiving postoperative morphine through a patient-controlled analgesic (PCA)
pump and the patients orders specify an initial bolus dose. What is your priority assessment? -
ANS Assessment for respiratory depression
A 52-year-old female patient is receiving care on the oncology unit for breast cancer that has
metastasized to her lungs and liver. When addressing the patients pain in her plan of nursing
care, the nurse should consider what characteristic of cancer pain? - ANS Cancer pain can be
acute or chronic and it typically requires comparatively high doses of pain medications.
A gerontologic nurse is teaching students about the high incidence and prevalence of
dehydration in older adults. What factors contribute to this phenomenon? Select all that apply. -
ANS Decreased kidney mass, decreased renal blood flow, decreased excretion of potassium
A nurse in the preoperative holding area is admitting a woman prior to reduction mammoplasty.
What should the nurse include in the care given to this patient? Select all that apply. - ANS
Establishing an IV line, verifying the surgical site with the patient, and taking measures to
ensure the patients comfort
A 21-year-old patient is positioned on the OR bed prior to knee surgery to correct a
sports-related injury.The anesthesiologist administers the appropriate anesthetic. The OR nurse
should anticipate which of the following events as the teams next step in the care of this
patient? - ANS Intubating
A patient will be undergoing a total hip arthroplasty later in the day and it is anticipated that the
patient may require blood transfusion during surgery. How can the nurse best ensure the
patients safety if a blood transfusion is required? - ANS Ensure that the patient has had a
current cross-match.
A patient is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a
chest tube into the anterior chest wall. What should the nurse tell the family is the primary
purpose of this chest tube? - ANS To remove air from the pleural space
A patients plan of care specifies postural drainage. What action should the nurse perform when
providing this noninvasive therapy? - ANS Assist the patient into a position that will allow
gravity to move secretions.
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