A nurse is flushing a client's intermittent infusion device. The client states, "Why do you have to do that if you are not giving me medicine?" Which of the following statements should the nurse make?

"This helps to keep you hydrated."

"This clears blood from the tubing and the catheter."

"This makes sure it stays sterile."

"This prevents leakage of fluid and medication."

Answer and Explanation

The Correct Answer is B

Rationale:

A. "This helps to keep you hydrated.": Flushing an intermittent infusion device does not hydrate the client, as the small amount of saline used is not intended for fluid replacement. Hydration is achieved through continuous or scheduled fluid administration, not flushes.

B. "This clears blood from the tubing and the catheter.": Flushing helps maintain catheter patency by preventing blood from clotting inside the lumen. It ensures the device remains functional and ready for medication administration when needed.

C. "This makes sure it stays sterile.": Flushing does not sterilize the device. Sterility is maintained through proper handling and use of aseptic technique. The purpose of flushing is mechanical, not antimicrobial.

D. "This prevents leakage of fluid and medication.": While flushing may help confirm that the device is intact, the primary reason is not to prevent leakage but to maintain patency and ensure the catheter is free of occlusions.

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Correct Answer is A

Explanation

Rationale:

A. Subdural hematoma: This condition increases the risk of complications during electroconvulsive therapy (ECT) due to potential elevated intracranial pressure. The seizure activity induced by ECT can further increase pressure and pose a risk of brain herniation or worsening of the hematoma.

B. Renal calculi: Kidney stones may cause pain and hematuria, but they do not directly increase the risk of complications during ECT. Unless there is severe renal impairment or electrolyte imbalance, ECT is generally safe for these clients.

C. Hyperthyroidism: While hyperthyroidism may increase sensitivity to stress or elevate the risk of arrhythmias during procedures, it does not present the same level of direct neurological risk as intracranial pathology like a subdural hematoma.

D. Diabetes mellitus: Diabetes requires careful monitoring during ECT, especially regarding fasting, blood glucose levels, and anesthetic recovery. However, it is not a contraindication and does not present as high a procedural risk as a brain bleed would.

A. Client's chief complaint B. Client's job performance history C. Client's relationships with family and friends D. Client's copying nurses words E. Client's statement about their mother F. Client's speech pattern

Correct Answer is ["A","D","E","F"]

Explanation

Rationale:

A. Client's chief complaint: Hearing voices is an auditory hallucination, which is a hallmark positive symptom of schizophrenia. Hallucinations reflect a distortion of reality and are typically responsive to antipsychotic treatment.

B. Client's job performance history: Poor job performance reflects functional decline, which is a negative symptom (e.g., avolition or anhedonia), not a positive one. It indicates loss of normal function rather than distortion.

C. Client's relationships with family and friends: Social withdrawal is another negative symptom, reflecting a lack of interest or emotional engagement. Positive symptoms are additions to normal experience, not losses like this.

D. Client's copying nurses' words: Repeating others’ words is known as echolalia, a disorganized thought manifestation commonly seen in schizophrenia. It indicates impaired cognitive processing and communication.

E. Client's statement about their mother: The delusional belief that their mother is trying to kill them represents a paranoid delusion, a classic positive symptom. Such fixed false beliefs are unrelated to reality and resistant to logic.

F. Client's speech pattern: Unclear, jumbled, and disorganized speech reflects disorganized thinking, another positive symptom of schizophrenia. This makes coherent communication and goal-directed behavior difficult.

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A nurse is flushing a client's intermittent infusion device. The client states, "Why do you have to do that if you are not giving me medicine?" Which of the following statements should the nurse make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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