Rational: Clients with antisocial personality disorder must have limits set on their behavior because they are artful in manipulating others. Answer B is not correct because they do express feelings and remorse. Answers C and D are incorrect because it is unnecessary to minimize interactions with others or encourage them to act out rage more than they already do.
2. Answer B
Rational: The client with passive-aggressive personality disorder often has underlying hostility that is exhibited as acting-out behavior. Answers A, C, and D are incorrect. Although these individuals might have a high IQ, it cannot be said that they have superior intelligence. They also do not necessarily have dependence on others or an inability to share feelings.
3.Answer C .
Rational: To prevent the client from inducing vomiting after eating, the client should be observed for 1–2 hours after meals. Allowing privacy as stated in answer A will only give the client time to vomit. Praising the client for eating all of a meal does not correct the psychological aspects of the disease; thus, answer B is incorrect. Encouraging the client to choose favorite foods might increase stress and
the chance of choosing foods that are low in calories and fats.
4. Answer B
Rational:. The first action that the nurse should take when beginning to examine the infant is to listen to the heart and lungs. If the nurse elicits the Babinski reflex, palpates the abdomen, or looks in the child’s ear first, the child will begin to cry and it will be difficult to obtain an objective finding while listening to the heart and lungs. Therefore, answers A, C, and D are incorrect.
5. Answer D is correct.Rational: Urokinase is a thrombolytic used to destroy a clot following a myocardial infraction. If the client exhibits overt signs of bleeding, the nurse should stop the medication, call the doctor immediately, and prepare the antidote, which is Amicar. Answer B is not correct because simply stopping the urokinase is not enough. In answer A, vitamin K is not the antidote for urokinase, and reducing the urokinase,as stated in answer B, is not enough.
6. Answer A is correct. Rational: The client taking calcium preparations will frequently develop constipation so the client should be assessed for any problems related to bowel elimination. Answers B, C, and D are not problems related to the use of calcium carbonate.
7. Answer C is correct.Rational: If the finger cannot be used, the next best place to apply the oxygen
monitor is to the earlobe. It can also be placed on the forehead, but the choices in answers A, B, and D are incorrect.
8. Answer A is correct.Rational: The client is exhibiting a widened pulse pressure, tachycardia,and tachypnea. The next action after obtaining these vital signs is to notify the doctor for additional orders. Rechecking the vitals signs, as in answer B, is wasting time. It is the doctor’s call to order arterial blood gases and an ECG.
9. Answer A is correct.Rational: The best time to apply antithrombolytic stockings is in the morning
before rising. If the doctor orders them later in the day, the client should return to bed, wait 30 minutes, and apply the stockings. Answers B, C, and D are incorrect because there is likely to be more peripheral edema if the client is standing or has just taken a bath; before retiring in the evening is wrong because, late in the evening, more peripheral edema will be present.
10. Answer C is correct. Rational: The client admitted 1 hour ago with shortness of breath should be seen first because this client might require oxygen therapy. The client in answer A with a low-grade temperature can be assessed after the client with shortness of breath. The client in answer B can also be seen later. This client will have some
11. Answer D is correct.Rational: Intrathecal medications are administered into the cerebrospinal fluid. This method of administering medications is reserved for the client with metastases, the client with chronic pain, or the client with cerebrospinal infections. Answers A, B, and C are incorrect because intravenous, rectal, and intramuscular injections are entirely different procedures.
12. Answer A is correct.Rational: The nurse who fails to wear gloves to remove a contaminated dressing needs further instruction. Answers B, C, and D are incorrect because they indicate an understanding of the correct method of completing these tasks.
13. Answer D is correct. Rational: The most suitable roommate for the client with gastric resection is the client with phlebitis because phlebitis is an inflammation of the blood vessel and is not infectious. Crohn’s disease clients, in answer A, have frequent stools that might spread infections to the surgical client. The client in answer B with pneumonia is coughing and will disturb the gastric client. The client with gastritis, in answer C, is vomiting and has diarrhea, which also will disturb the gastric client.
14. Answer C is correct. Rational: When the client is receiving TPN, the blood glucose level should be drawn. TPN is a solution that contains large amounts of glucose. Answers A, B, and D are not directly related to the question and are incorrect.
15. Answer A is correct. Rational:, AST, is not specific for myocardial infarction.Troponin, CK-MB, and myoglobin, in answers B, C, and D, are more specific, although myoglobin is also elevated in burns and trauma to muscles.
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