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NEW QUESTION 25
A 29-year-old client is admitted for a hysterectomy. She has repeatedly told the nurses that she is worried about having this surgery, has not slept well lately, and is afraid that her husband will not find her desirable after the surgery. Shortly into the preoperative teaching, she complains of a tightness in her chest, a feeling of suffocation, lightheadedness, and tingling in her hands. Her respirations are rapid and deep.
Assessment reveals that the client is:
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Classic symptoms of a heart attack include heaviness or squeezing pain in the chest, pain spreading to the jaw, neck, and arm. Nausea and vomiting, sweating, and shortness of breath may be present. The client does not exhibit these symptoms. (B) Clients suffering from anxiety or fear prior to surgical procedures may develop hyperventilation. This client is not seeking attention. (C) Symptoms of complete airway obstruction include not being able to speak, and no airflow between the nose and mouth. Breath sounds are absent. (D) Tightness in the chest; a feeling of suffocation; lightheadedness; tingling in the hands; and rapid, deep respirations are signs and symptoms of hyperventilation. This is almost always a manifestation of anxiety.
NEW QUESTION 26
A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?
Answer: B
Explanation:
(A) This statement is an example of adaptive rationalization. She is coping with her disappointment by rationalizing. This is adaptive because no harm is done to self or others. It is used to protect her ego. (B) This is an example of maladaptive suppression. She is suppressing the seriousness of the lump. It is maladaptive because delaying treatment will cause harm to her. (C) The client's actions are an example of maladaptive denial. She is denying her son's death by not facing his possessions. Until she faces his death, she cannot face reality. (D) This is an example of adaptive suppression. She realizes the impact of her husband's statement but delays discussion until she can devote her full attention to the matter.
NEW QUESTION 27
Which of the following nursing care goals has the highest priority for a child with epiglottitis?
Answer: B
Explanation:
Explanation/Reference:
Explanation:
(A) Of these four goals, maintenance of a calm, quiet atmosphere to reduce anxiety and to allow for rest is the most important. (B) Although nutrition is important, the child needs fluids to maintain fluid and electrolyte balance more than solid foods. In addition, the child may not be able to swallow solid foods owing to epiglottic swelling. (C) This goal is unrealistic because fever is a common symptom of the infection associated with epiglottitis. (D) If overexerted, the child will need more O2 and energy than available, and these requirements may exacerbate the condition.
NEW QUESTION 28
A client has been admitted to the labor and delivery unit in active labor. After assessing her, the RN notes that the client's fetus position is left occipital posterior. Which of the following statements best describes what this means to the labor process:
Answer: B
Explanation:
Explanation
(A) Posterior position causes a larger diameter of the fetal head to enter the pelvis than an anterior position.
Pressure on the sacral nerves is increased, and it takes the fetus a longer time to enter the pelvic inlet. (B) This position will prolong the first stage of labor. When the larger diameter of the fetal head enters the pelvis first, it will have a more difficult time accommodating to the pelvis; therefore, it will take a longer time for the fetus to move through the pelvis. (C) It will increase the time of labor because the larger diameter of the fetal head will have a more difficult time accommodating to the pelvic inlet and thus will move through the pelvis slower. (D) In the third stage of labor the placenta is delivered; therefore, the infant has been delivered.
NEW QUESTION 29
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