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9 Cards in this Set
- Front
- Back
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The family of a 14-year-old client with Attention-Deficit Hyperactivity Disorder (ADHD) is requesting the nurse’s assistance in implementing strategies in the client’s management of ADHD. Which of the following strategies should be reinforced in the management of ADHD for an adolescent client? Select all that apply. |
Select one or more:a. Model positive behaviors.b. Offer verbal instruction combined with visual cues.c. Plan structured activities in the afternoon.d. Use charts to assist with organization.e. Introduce new situations slowly.
Answer
a. Model positive behaviors. Parents, teachers and role models should model positive behavior to help the client cope with appropriate behavioral outcomes in all different situations. b. Offer verbal instruction combined with visual cues. Offering verbal instruction with visual cues can help the client better focus on the request or task. d. Use charts to assist with organization. Using charts to assist in staying organized is a good measure.
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A nurse is part of an interprofessional team. What qualities will the nurse use to implement effective collaboration. Select all that apply. |
Select one or more: a. Critical Thinking
b. Coercive behavior
c. Structured decision-making
d. Agressive reasoning
e. Assertive communication
Answer
a. Critical Thinking Critical Thinking is an effective quality to implement collaboration.
c. Structured decision-making Using structure to make new decisions is a good trait for collaborative work.
e. Assertive communication
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Place in order of priority, which clients the nurse will visit first to last.
A. A client receiving IV chemotherapy and the infusion pump is alarming.
B. A client who is ordered to be discharged.
C. A client who is one day post chest tube insertion for pneumothorax.
D. A client in wrist restraints who has a sitter in the room.
E. A client admitted via the Emergency Department three hours ago with the diagnosis of "acute abdomen".
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Select one: a. A, B, D, E, C
b. D, E, B, C, A
c. A, E, C, D, B
d. B, C, D, E, A
Answer
c. A, E, C, D, B Rationale: A. The client receiving chemotherapy is the first order of priority because the chemo therapeutic drug may be infiltrating or the line may be occluded. If the infusion site has infiltrated, it could cause tissue damage. If the line has occluded, measures to regain patency must be carried out quickly or the line will be lost. E. The next client is a new admission from the emergency department and current baseline status needs to be assessed rapidly. C. Next the status of the chest tube must be assessed. The purpose of the chest tube is to provide for lung re-expansion. If the tube is not functioning properly, the client will be in respiratory distress and will require rapid intervention. D. This client is in wrist restraints and the nurse must assess circulation and check in with the sitter. B. The client being discharged today would be considered the most stable of the clients.
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A client diagnosed with depression is taking the medication phenelzine, a monoamine oxidase inhibitor (MAOI). What teaching on food choices should the nurse reinforce with the client to avoid the adverse effect of hypertensive crisis? Select all that apply. |
Select one or more: a. Oats
b. Salami
c. Bananas
d. Basil
e. Avocados
Answer
b. Salami
c. Bananas e. Avocados
Avocado, banana, salami are foods high in tyramine. When a client is on a MAOI, foods high in tyramine should be avoided to prevent the adverse effect, hypertensive crisis.
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The nurse is reinforcing discharge teaching with a client who is hearing impaired. Which of the following communication strategies would be effective for the nurse to include in the plan of care? Select all that apply. |
Select one or more: a. Ask family members to interpret.
b. Speak clearly and slowly.
c. Use hand-gestures and symbols to reinforce key points.
d. Arrange for closed-captioning of video presentations.
e. Provide teaching in a quiet room.
Answer
b. Speak clearly and slowly.
CORRECT. The nurse should speak clearly and slowly, without shouting. Shouting raises the frequency of the voice, so client’s with high-frequency hearing loss will not be able to hear what the nurse is saying if she is shouting. Speaking slowly is important because many people with hearing loss are able to read lips.
d. Arrange for closed-captioning of video presentations. CORRECT. Closed captioning of video presentations would be an appropriated communication strategy for the hearing impaired client. e. Provide teaching in a quiet room. CORRECT. The nurse should be facing the client in a well-lit, quiet room without distractions.
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A client who has undergone a mastectomy expresses concern about her body image. What nursing interventions would be appropriate for this client? Select all that apply. |
Select one or more: a. Arrange for someone from a local support group to come and meet with the client.
b. Advise to avoid taking blood pressure from the arm on the affected side.
c. Reinforce teaching with the client about breast prostheses including properly fitting of prosthesis.
d. Encourage the client to discuss reconstruction alternatives with the surgeon.
e. Refer the client to home health services to provide for needs following discharge.
Answer
a. Arrange for someone from a local support group to come and meet with the client.
Speaking with someone who has had a similar experience allows the client to discuss fears and concerns associated with her body image.
c. Reinforce teaching with the client about breast prostheses including properly fitting of prosthesis. Education on prostheses may assist the client in maintaining a positive body image. d. Encourage the client to discuss reconstruction alternatives with the surgeon. Learning about reconstruction opportunities specifically addresses body image issues and helps to provide long-term solutions.
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A nurse is monitoring a client undergoing electroconvulsive therapy (ECT). What data should be collected by the nurse during this therapy? Select all that apply. |
Select one or more: a. Long-term memory loss
b. Hypotension or hypertension
c. Intestinal obstruction
d. Respiratory rate and effort
e. Duration of the seizure
Answer
b. Hypotension or hypertension BP may initially fall and then rise during the procedure.The elevated BP should resolve shortly after the termination of the treatment. d. Respiratory rate and effort The client is sedated with a short acting anesthetic, such as methohexital (Brevital) and a muscle relaxant, such as succinylcholine chloride. Therefore, monitoring the client’s airway and respiratory rate and effort will allow for prompt intervention if needed. e. Duration of the seizure Seizure duration usually lasts 25-60 seconds. Seizures lasting longer than 90 seconds should be treated with diazepam (Valium).
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During a family therapy session, a client diagnosed with bipolar disorder states, “My family does not understand my bipolar disease.” The client’s family expresses concern to the nurse that the client may not be responding to the prescribed medication. Place the following interventions for promoting positive outcomes to therapy in the order of priority.
A. Assist the client and family to find strengths on which to capitalize. B. Provide therapeutic and medication education. C. Identify and clarify concerns of both the client and family D. Review further as to why the family feels the client is not responding to the medication. E. Provide a non-manipulative and decentralized communicative environment.
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Select one: a. E, C, D, A, B b. B, A, D, E, C c. A, C, D, E, B d. E, B, D, A, C Answer a. E, C, D, A, B Rationale:E. In the initial phase of family therapy, the nurse sets a tone of respect, trust and confidentiality among members while maintaining open and clear communication. C. Investigation of concerns by first identifying and then clarifying the concerns prevents misconceptions and assumptions and allows the nurse to accurately assess problems/misinformation. D. Examination of specific concerns voiced by the client/family provides the client and family the opportunity to fully explain issues. A. Identifying family strengths and common goals, reinforcing existing effective coping mechanisms already used by the family members, and determining new skills that family members can use at this time provides hope and assists the client and family to stay focused on achieving the goals of therapy. B. Once the family is communicating, has clarified issues of concern, and recognizes that the tools are available to achieve the desired goals, it is important to determine learning/teaching needs of the family, and then meet those needs with accurate and timely information.
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A nurse is evaluating a client who is exhibiting violent behavior. Which of the following should the nurse consider before applying restraints? Select all that apply. |
Select one or more: a. Use the smallest amount of force necessary when applying a restraint. b. Nurse Practitioners can prescribe restraints. c. The most restrictive restraint should be used for a violent client. d. Restraints should be applied immediately to avoid client injury. e. Restraints must be released according to the protocol. Answer a. Use the smallest amount of force necessary when applying a restraint. Restraints are applied with a minimum of force and only when necessary and when other alternatives have been unsuccessful. e. Restraints must be released according to the protocol. Restraints must be released according to the restraint protocol of the institution.This must be done to observe skin integrity, circulatory status, respiratory status, etc.
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