Nclex Prep
The ideal number of clients in a psychotherapy group
7 to 10. Having more than 10 members is not recommended because the group will subdivide, which is counterproductive. Too large a group also can create more opportunities for acting out as opposed to working through issues. None of the other options is necessarily true.
A client brought to the emergency department is dead on arrival (DOA). The health care provider (HCP) examines the client and asks the nurse to contact the medical examiner regarding an autopsy. The spouse of the client tells the nurse that she does not want an autopsy performed. Which response should the nurse make?
An autopsy is required by state law in certain circumstances, including the sudden death of a client and a death that occurs under suspicious circumstances. The client may have provided oral or written instructions regarding an autopsy following death. If an autopsy is not required by law, these oral or written requests will be granted. If no oral or written instructions were provided, state law determines who has the authority to consent for an autopsy. Most often, the decision rests with the surviving relative or next of kin. The correct option addresses the client's (the spouse) feelings and addresses the issue. In addition, the nurse acts as an advocate and is compassionate in telling the client that he or she will stay with the spouse when she speaks to the HCP.
The nurse is caring for a client who was involuntarily hospitalized to a mental health unit and is scheduled for electroconvulsive therapy. The nurse notes that an informed consent has not been obtained for the procedure. Based on this information, what is the nurse's best determination in planning care?
Clients who are admitted involuntarily to a mental health unit do not lose their right to informed consent. Clients must be considered legally competent until they have been declared incompetent through a legal proceeding. The best determination for the nurse to make is to obtain the informed consent from the client.
The mental health nurse is meeting with a client who has a long history of abusing drugs. During the session the client says to the nurse, "I'm feeling much better now, and I'm ready to go straight." Which response by the nurse would be therapeutic?
Clients with a long history of drug abuse need to demonstrate motivation to change the behavior, not just verbalization of the behavior. The therapeutic response by the nurse would be directed at assisting the client to look at the behaviors that indicate the change. The correct option is the only one that will provide this direction to the client.
The nurse reinforces medication instructions on therapy with cyclosporine to a client who has received a kidney transplant. Which statement by the client would indicate a need for further instruction?
Cyclosporine is an immunosuppressant medication. Because of the effects of the medication, the client should not receive any vaccinations without first consulting the health care provider. The client should report decreased urine output or cloudy urine, which could indicate kidney rejection or infection, respectively. The client needs meticulous oral care and dental cleaning every 3 months to help prevent gingival hyperplasia. The client must be able to self-monitor blood pressure to check for the side effect of hypertension.
A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise?
Exercise is an important part of diabetes management. It promotes weight loss, decreases insulin resistance, and helps to control blood glucose levels. A hypoglycemic reaction may occur in response to increased exercise, so clients should exercise either an hour after mealtime or after consuming a 10- to 15-gram carbohydrate snack, and they should check their blood glucose level before exercising.
A client is suspected of having stage I Lyme disease. The nurse anticipates that which will be part of the treatment plan for the client?
Lyme disease is a reportable systemic infectious disease caused by the spirochete Borellia burgdorferi and results from the bite of an infected deer tick, also known as the black-legged tick. Prevention, public education, and early diagnosis are vital to the control and treatment of Lyme disease. A 14 to 21 day course of oral antibiotic therapy is recommended during stage I. Later stages of Lyme disease may require therapy with intravenously administered antibiotics, such as penicillin G. The remaining options are incorrect
The nurse is caring for a client who was recently diagnosed with primary open-angle glaucoma (POAG). Which assessment finding is specific to this type of glaucoma?
POAG results from obstruction to outflow of aqueous humor and is the most common type. Assessment findings include painless vision changes and "tunnel vision." Primary angle-closure glaucoma (PACG) is another type of glaucoma that results from blocking the outflow of aqueous humor into the trabecular meshwork. Assessment findings include blurred vision, ocular erythema, and halos around lights.
Pronator drift
Pronator drift occurs when a client cannot maintain the hands in a supinated position with the arms extended and the eyes closed. This assessment may be done to detect small changes in muscle strength that might not otherwise be noted. Ataxia is a disturbance in gait. Nystagmus is characterized by fine, involuntary eye movements. Hyperreflexia is an excessive reflex action.
instructions to a client regarding the use of a hearing aid?
The client should be instructed that the hearing aid should not be worn if an ear infection is present. The client should wash the ear mold frequently with mild soap and water and use a pipe cleaner to clean the cannula of the hearing aid. The client should be instructed to turn off the hearing aid before removing it from the ear to prevent any squealing feedback. The hearing aid should be turned off when not in use, and the client should keep extra batteries on hand at all times.
client with a continuous passive motion device applied to the leg about the device and its use
The client should not adjust the flexion and extension settings. These settings are determined by the orthopedic surgeon and are maintained as prescribed. The client is instructed about how to stop and start the machine and about the need to notify the nurse if the client experiences knee discomfort. The client also should be aware of proper positioning so that the nurse can be notified if the leg slips. Other important actions by the nurse with use of this device are to assess the neurovascular status of the extremity and to ensure that the device is padded with manufactured disposable padding before the client's leg is placed in the device.
The nurse is assessing a client with the typical clinical manifestations of tuberculosis (TB). During history-taking the nurse anticipates that the client will report presence of cough and fatigue for what period of time?
The client with TB may report signs and symptoms that have been present for weeks or even months. These may include fatigue, lethargy, chest pain, anorexia and weight loss, night sweats, low-grade fever, and cough with mucoid or blood-streaked sputum. It may be the production of blood-tinged sputum that finally forces some clients to seek care
A client is diagnosed with Bell's palsy. The nurse assessing the client expects to note which symptom?
The facial drooping associated with Bell's palsy makes it difficult for the client to close the eyelid on the affected side. A widening of the palpebral fissure (the opening between the eyelids) and an asymmetrical smile are seen with Bell's palsy. Paroxysms of excruciating pain are characteristic of trigeminal neuralgia.
A 7-year-old child is hospitalized with a fracture of the femur and is placed in traction. In meeting the psychosocial needs of the child, the nurse most appropriately selects which play activity for the child?
The school-age child becomes organized with more direction with play activities. Such activities include collections, drawing, construction, dolls, pets, guessing games, board and computer games, riddles, hobbies, competitive games, and listening to the radio or television. Finger-painting and coloring are appropriate for a preschooler. Completing a large puzzle is appropriate for a toddler.
A client who suffered carbon monoxide poisoning from working on an automobile in a closed garage has a carbon monoxide level of 15%. The nurse should anticipate observing which sign or symptom?
The signs and symptoms worsen as the carbon monoxide level rises in the bloodstream. Impaired visual acuity occurs at 5% to 10%, whereas flushing and headache are seen at 11% to 20%. Nausea and impaired dexterity appear at levels of 21% to 30%, and a 31% to 40% level is accompanied by vomiting, dizziness, and syncope. Levels of 41% to 50% cause tachypnea and tachycardia, and those higher than 50% result in coma and death.
After review of the client's laboratory values, the nurse notes that a phenytoin level for a client receiving phenytoin is 7 mcg/mL
The target range for a therapeutic serum level of phenytoin is between 10 and 20 mcg/mL (40 to 79 mmol/L). Levels below 10 mcg/mL are too low to control seizures. At levels above 20 mcg/mL (79 mmol/L), signs of toxicity begin to appear. This client has a low serum level, and the dosage is likely to be increased
The nurse is taking a history from a client suspected of having testicular cancer. Which data will be most helpful in determining the risk factors for this type of cancer?
Two basic but important risk factors for testicular cancer are age and race. The disease occurs most frequently in white males, generally between the ages of 15 and 34 years. Other risk factors include a history of undescended testis and a family history of testicular cancer. Marital status and number of children are not associated with increased risk of testicular cancer. In addition, the number of sexual partners is not associated with testicular cancer.
The nurse is caring for a client diagnosed with Alzheimer's disease who is demonstrating characteristics of agnosia
When illness (Alzheimer's disease) affects the temporal-parietal-occipital association cortex, the client may experience the inability to identify well-known objects and people. This is called agnosia. Ataxia describes altered motor function. The client also may experience difficulty finding the right word to use, called aphasia, and an inability to perform familiar skilled activities, called apraxia
Which interventions are most appropriate for caring for a client in alcohol withdrawal? Select all that apply.
When the client is experiencing withdrawal from alcohol, the priority for care is to prevent the client from harming self or others. The nurse would monitor the vital signs closely and report abnormal findings. The nurse would provide a low-stimulation environment to maintain the client in as calm a state as possible. The nurse would reorient the client to reality frequently and would address hallucinations therapeutically. Adequate nutritional and fluid intake need to be maintained.
he nurse assigned to care for a female client diagnosed with acute depression would be appropriate in making which statement to the client?
he nurse assigned to care for a female client diagnosed with acute depression would be appropriate in making which statement to the client?