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NEW QUESTION 54
A 9-week-old female infant has a diagnosis of bilateral cleft lip and cleft palate. She has been admitted to the pediatric unit after surgical repair of the cleft lip. Which of the following nursing interventions would be appropriate during the first 24 hours?

A. Offer pacifier when she cries.B. Maintain elbow restraints in place unless she is being directly supervised.C. Position on side or abdomen.D. Clean suture line every shift.

Answer: B

Explanation:
(A) Placing the infant on her abdomen may allow for injury to the suture line. (B) Elbow restraints prevent the infant from touching the suture line and yet leaves hands free. (C) The suture line is cleaned as often as every hour to prevent crusting and scarring. (D) Sucking of a bottle or pacifier places pressure on the suture line and may delay healing and cause scarring.

 

NEW QUESTION 55
A male client has burns over 90% of his body after an automobile accident resulting in a fire. He was trapped inside the auto and pulled out by a bystander. After several months in the hospital and over 20 surgeries, discharge planning has begun. Throughout his hospitalization the nursing staff has been aware of psychological changes the client faces after burns over a large portion of his body resulting in disfigurement. The nursing staff can best foster the client's self-esteem by:

A. Allowing him to plan, assist in, and perform his own care whenever possibleB. Adhering to a strict schedule of diet, exercise, and wound careC. Allowing him to go to physical therapy for whirlpool treatment when other clients were not in physical therapyD. Following a standardized plan of care for burn clients formulated by a world-renowned burn center

Answer: A

Explanation:
(A) A regimented schedule, allowing no flexibility, will not foster the client's self-esteem. (B) Isolating the client may only enhance his feelings of social isolation due to his disfigurement. (C) Standardized care plans must be personalized and adapted to each client's situation. (D) Allowing the client control over his care will foster his self-esteem and prepare him for life outside of the hospital.

 

NEW QUESTION 56
Three weeks following discharge, a male client is readmitted to the psychiatric unit for depression. His wife stated that he had threatened to kill himself with a handgun. As the nurse admits him to the unit, he says, "I wish I were dead because I am worthless to everyone; I guess I am just no good." Which response by the nurse is most appropriate at this time?

A. "I don't think you are worthless. I'm glad to see you, and we will help you."B. "Don't you think this is a sign of your illness?"C. "You've been feeling sad and alone for some time now?"D. "I know with your wife and new baby that you do have a lot to live for."

Answer: C

Explanation:
(A)
This response does not acknowledge the client's feelings.
(B)
This is a closed question and does not encourage communication.
(C)
This response negates the client's feelings and does not require a response from the client. (D) This acknowledges the client's implied thoughts and feelings and encourages a response.

 

NEW QUESTION 57
Which of the following physician's orders would the nurse question on a client with chronic arterial insufficiency?

A. Elevate legs on pillowsB. No smokingC. Neurovascular checks every 2 hoursD. Arteriogram in the morning

Answer: A

Explanation:
Explanation
(A) Neurovascular checks are a routine part of assessment with clients having this diagnosis. (B) Elevation of the legs is contraindicated because it reduces blood flow to areas already compromised. (C) Arteriogram is a routine diagnostic order. (D) Smoking is highly correlated with this disorder.

 

NEW QUESTION 58
A 22-year-old client presents with a diagnosis of antisocial personality disorder and a history of using drugs, writing numerous checks with insufficient funds, and stealing. He appears charming and intelligent, and the other clients are impressed and want to be liked by him. The greatest problem that may arise from this situation is that:

A. He will cause the other clients to become psychoticB. He will become delusional and hallucinate as a result of the excess attention given to him by peersC. He will manipulate the other clients for his own benefitD. He may exhibit self-mutilative behavior

Answer: C

Explanation:
Explanation
(A) This answer is correct. Persons with antisocial personality disorder typically are very manipulative. (B) This answer is incorrect. The client's behavior cannot cause another person to become psychotic. (C) This answer is incorrect. Psychosis is not a symptom of antisocial personality. One of the criteria for diagnosis of this disorder is that no psychosis be present. In addition, the client would love the attention. (D) This answer is incorrect. Self-mutilative behavior is characteristic of the borderline personality disorder.

 

NEW QUESTION 59
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