A nurse is preparing a young adult client who has a hearing impairment for surgery. Which of the following actions should the nurse take?

Allow the client to take her morning vitamins.

Allow the client to keep her tongue stud in.

Allow the client to consume clear liquids up to the time of surgery.

Allow the client to keep her hearing aids in.

Answer and Explanation

The Correct Answer is D

Choice A reason: It is not recommended for clients to take morning vitamins before surgery due to the risk of aspiration and interference with anesthesia.

Choice B reason: Clients are typically instructed to remove all jewelry, including tongue studs, to prevent complications during surgery.

Choice C reason: Clients are generally required to fast before surgery, which includes not consuming clear liquids, to reduce the risk of aspiration.

Choice D reason: Allowing the client to keep her hearing aids in is important for communication and to reduce anxiety due to hearing impairment.

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Correct Answer is A

Explanation

Choice A reason: An illusion is a misinterpretation of a real external stimulus. Mr. S is mistaking the cracks in the plaster for snakes, which is an illusion.

Choice B reason: A flashback is a vivid memory of a traumatic event that feels like it is happening again. This does not describe Mr. S's experience.

Choice C reason: A hallucination is a sensory experience of something that does not exist outside the mind. Since Mr. S is misinterpreting an actual visual stimulus (the cracks), it is not a hallucination.

Choice D reason: A delusion is a firmly held false belief resistant to reason or confrontation with actual fact. Mr. S's belief is based on a misinterpretation of a visual stimulus, not a delusion.

A. Bounding pulse. B. Elevated temperature. C. Warmth at IV site. D. Profuse sweating. E. Crackles in lungs.

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

Explanation

Choice A reason: A bounding pulse can indicate fluid volume excess, as the heart works harder to pump the increased volume.

Choice B reason: Elevated temperature is not specifically indicative of fluid volume excess and can be related to various conditions.

Choice C reason: Warmth at the IV site may indicate an infection or inflammation, not necessarily fluid volume excess.

Choice D reason: Profuse sweating is not typically a sign of fluid volume excess; instead, it may indicate dehydration or other conditions.

Choice E reason: Crackles in the lungs can indicate fluid overload, especially in the context of excessive IV fluid administration.

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A nurse is preparing a young adult client who has a hearing impairment for surgery. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Mr. S states, "Look at the snakes on the ceiling!" You see some cracks in the plaster. Mr. S is experiencing a/an:

Correct Answer is A

Explanation

A patient is receiving IV fluids at 100 mL per hour. Which assessment findings would indicate fluid volume excess? (Select all that apply.)

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

Explanation

A schizophrenic client is being assessed by the nurse. The client is demonstrating negative symptoms. Which symptoms should be considered negative? (select all that apply)

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Nursing care for people with personality disorders includes all the following except:

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