8/10/2019 24 Nclex Review

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65. A young woman is transferred to a psychiatric crisis unit with a

diagnosis of a dissociative disorder. The nurse knows which of the following

comments by the client is MOST indicative of this disorder?

1. I keep having recurring nightmares.2. I have a headache and my stomach has bothered me for a week.

3. I always check the door locks three times before I leave home.4. I dont know who I am and I dont know where I live.

Strategy: Think about each answer choice.(1) posttraumatic stress disorder (PTSD) is characterized by anxiety and stress

symptoms that occur after an intense traumatic event; characteristic symptoms arehypervigilance, insomnia, and recurring nightmares

(2) somatoform disorder (or hypochondria) is concerned with physical and emotionalhealth, accompanied by various bodily complaints for which there is no physical basis

(3) reflects the compulsive checking behavior of the anxiety associated with

obsessive-compulsive disorder(4) correctdissociative disorders characterized by either a sudden or a gradual

disruption in the integrative functions of identity, memory, or consciousness;

disruption may be transient or may become a well-established pattern; developmentof these disorders is often associated with exposure to a traumatic event

66. An older woman comes to the outpatient clinic because she has not beenfeeling well for several days. During the admission interview, the nurse

learns that the client has a history of congestive heart failure (CHF), is on a

low-sodium diet, and has been taking chlorothiazide (Diuril) 500 mg POdaily for 6 months. Diagnostic tests indicate: sodium 127mEq/L, potassium

3.8mEq/L, glucose 110mg/dL, and normal chest x-ray. The signs andsymptoms the nurse would expect the client to

exhibit include

1. sticky mucous membranes, decreased urinary output, and firm, rubbery tissues.

2. cool moist skin, fine hand tremors, and mental confusion.3. headache, apprehension, and lethargy.

4. shortness of breath, chest pain, and anxiety.

Strategy: Determine the significance of each answer choice.(1) symptoms of hypernatremia, along with restlessness, weakness, coma,

tachycardia, flushed skin, oliguria, fever(2) symptoms of hypoglycemia, normal blood sugar 70-110 mg/dL

(3) correctsymptoms of hyponatremia along with muscle twitching, convulsions,diarrhea, fingerprinting of skin

(4) symptoms of CHF, chest x-ray clear, no other information provided

67. The nurse is caring for a patient following an appendectomy. The patienttakes a deep breath, coughs, and then winces in pain. Which of thefollowing statements, if made by the nurse to the patient, is BEST?

1. Take three deep breaths, hold your incision, and then cough.

2. That was good. Do that again and soon it wont hurt as much.

3. It wont hurt as much if you hold your incision when you cough.4. Take another deep breath, hold it, and then cough deeply.