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NEW QUESTION 37
A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:
Answer: C
Explanation:
(A) There is no NPO restriction prior to a liver biopsy. (B) The client would need to hold his breath for 5-10 seconds. (C) There is no pretest laxative given. (D) Following the test, the client is watched for hemorrhage and shock.
NEW QUESTION 38
The nurse working with a client who is out of control should follow a model of intervention that includes which of the following?
Answer: B
Explanation:
Explanation
(A) Approaching a client's aggressive behavior on a continuum of least restrictive care is in agreement with his or her rights (i.e., verbal methods to help maintain control, medication, seclusion, and restraints, as necessary). (B) Approaching a client in a challenging manner is threatening and inappropriate. A nonchallenging and calm approach reflects staff in control and may increase client's internal control. (C) It is inappropriate to leave an aggressive client who is acting out alone. The nurse should acquire qualified help to prevent client from harm or injury to self or others. (D) Moving a client to seclusion immediately for shouting is inappropriate. The nurse should offer the client an opportunity to control self with limit setting. The client should understand that the staff will assist with control if necessary (i.e., quietly accompany out of environment to decrease stimulation and allow for verbalization) employing the least restrictive care model of intervention.
NEW QUESTION 39
A female client has experienced varying degrees of depression throughout her life. Now that she is postmenopausal, her depression has increased. She is unable to motivate herself to clean her house or even to get out of bed and get dressed in the morning. The client was begun on fluoxetine (Prozac) therapy. When educating her about fluoxetine, what might the nurse caution her about?
Answer: C
Explanation:
Explanation/Reference:
Explanation:
(A) A daily dose of fluoxetine should be taken in the morning. Afternoon doses may cause nervousness and insomnia. (B) Although fluoxetine is less sedating than other antidepressants, it may still cause dizziness or drowsiness in some clients. The nurse should caution clients to avoid driving or hazardous activities until the central nervous system effects of the drug are demonstrated. (C) Rashes or pruritus do commonly occur early in therapy and respond to antihistamines or topical corticosteroids. (D) Advise the client not to take over-the-counter or other prescription drugs without consulting with the physician.
Fluoxetine does interact with other common drugs such as monoamine oxidase inhibitors, diazepam, insulin, oral antidiabetic agents, tricyclic antidepressants, and tryptophan.
NEW QUESTION 40
On a mother's 2nd postpartum day after having a vaginal delivery, the RN is preparing to assess her perineum and anus as part of her daily assessment. The best position for the client to be placed in for this assessment is:
Answer: A
Explanation:
Section: Questions Set C
Explanation:
(A) The Sims' position is the best position for assessment of the perineum and anus. The top leg is placed over the bottom leg, and the RN raises the upper buttocks to fully expose the perineum and anus. (B) Fowler's position is a sitting position, and the perineum and anus would not be exposed. (C) The prone position would have the mother on her back, and her perineum and anus would not be exposed. (D) The position of choice should always be the Sims'.
NEW QUESTION 41
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