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For each assessment finding, click to specify if the finding is consistent with psychosis or mania.
- A. Hallucinations
- B. Lack of sleep
- C. Excessive spending habits
- D. Disorganized thought process
- E. Pressured speech
Correct Answer: A,B,C,D,E
Rationale: The correct answer is A, B, C, D, E. Hallucinations, lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are all consistent with both psychosis and mania. Hallucinations are sensory perceptions without a real external stimulus, common in both conditions. Lack of sleep is a hallmark symptom of mania and can also exacerbate psychotic symptoms. Excessive spending habits are often seen in manic episodes due to impulsivity, and disorganized thought process and pressured speech are characteristic of both psychosis and mania, reflecting the underlying cognitive and communication disturbances. Other choices are not specific or commonly associated with psychosis or mania.
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Which of the following actions should the nurse take first?
- A. Encourage the family to assign specific tasks to individual family members.
- B. Determine the roles of individual family members.
- C. Assist the family to establish a daily routine
- D. Refer the family to a grief support group.
Correct Answer: B
Rationale: The correct answer is B: Determine the roles of individual family members. This is the first step because it helps identify the strengths and abilities of each family member, allowing for effective delegation of tasks and responsibilities. By understanding each member's role, the nurse can promote a balanced distribution of duties and enhance the family's ability to cope with the situation. Encouraging the family to assign specific tasks (A) may be premature without knowing each member's capabilities. Establishing a daily routine (C) can come after roles are determined to provide structure. Referring to a grief support group (D) may be necessary but not the first step.
The client is at highest risk for developing--------- evidenced by the client's--------
- A. Rheumatoid arthritis
- B. decreased Hct and Hgb levels
- C. ESR level
- D. Systemic lupus erythematosus
- E. Anemia evidenced by the client's
- F. Gout evidenced
- G. decreased WBC count
Correct Answer: D,G
Rationale: Decreased WBC count and elevated ESR suggest systemic lupus erythematosus.
The nurse should set the IV infusion to deliver how many ml/hr?
- A. mL/hr
- B. 11.0 mL/hr
- C. 6.0 mL/hr
- D. 16.0 mL/hr
Correct Answer: B
Rationale: The correct answer is B: 11.0 mL/hr. This is the correct answer because the question asks how many mL/hr the nurse should set the IV infusion to deliver. The specific rate of 11.0 mL/hr is likely calculated based on the patient's individual needs, prescribed fluid volume, and the desired rate of administration. Option A is too general and does not provide a specific rate. Options C and D are incorrect as they do not match the recommended rate of 11.0 mL/hr given in the question.
A nurse is assessing a client who received hydromorphone 4mg IV 15 min ago. The client has a respiratory rate of 10/min. the nurse should prepare to administer which of the following medications?
- A. Naloxone
- B. Flumazenil
- C. Activated charcoal
- D. Atropine
- E. Diphenhydramine
Correct Answer: A
Rationale: The correct answer is A: Naloxone. Hydromorphone is an opioid that can cause respiratory depression. The client's low respiratory rate of 10/min indicates potential opioid overdose. Naloxone is an opioid antagonist that reverses the effects of opioids, such as respiratory depression. Administering naloxone can help restore normal breathing in the client. Flumazenil (B) is used to reverse the effects of benzodiazepines, not opioids. Activated charcoal (C) is used for toxin ingestion, not opioid overdose. Atropine (D) is a medication used for bradycardia, not respiratory depression. Diphenhydramine (E) is an antihistamine and is not indicated in this situation.
Which information should the nurse include?
- A. This type of seizure can be mistaken for daydreaming
- B. Absence seizures typically last only a few seconds.
- C. The child may not remember the seizure episode afterward.
- D. There are usually no warning signs before an absence seizure occurs.
- E. Lip smacking or eye fluttering may accompany the seizure.
Correct Answer: E
Rationale: The correct answer is E because lip smacking or eye fluttering are common manifestations of absence seizures, providing crucial information for recognition and diagnosis. Choice A is incorrect as it does not specifically relate to absence seizures. Choice B is incorrect because absence seizures typically last 10-20 seconds, not just a few seconds. Choice C is incorrect as individuals experiencing absence seizures usually do not have memory issues afterward. Choice D is incorrect because some individuals may have warning signs before an absence seizure.