Nokea
The nurse is caring for a client with hyperparathyroidism who had a parathyroidectomy 4 hours ago. Which technique should the nurse use to check for complications in this client?
- A. Ask the client to place the backs of the hands against each other to provide hyperextension of the wrist while the elbows remain flexed
- B. Perform the Romberg test by asking the client to stand with the eyes closed and the feet together
- C. Place a blood pressure (BP) cuff on the client's arm, inflate to pressure greater than systolic BP, and monitor for carpal spasm
Correct Answer: C
Rationale: Post-parathyroidectomy, hypocalcemia is a potential complication due to reduced parathyroid hormone levels. Trousseau’s sign (C), elicited by inflating a BP cuff to induce carpal spasm, indicates hypocalcemia, a critical complication requiring prompt intervention. The wrist hyperextension test (A) is unrelated to hypocalcemia, and the Romberg test (B) assesses balance, not relevant to this scenario.
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The nurse is observing a client with an obsessive-compulsive disorder in an inpatient setting. Which behavior is consistent with this diagnosis?
- A. Repeatedly checking that the door is locked
- B. Verbalized suspicions about thefts
- C. Preference for consistent caregivers
- D. Repetitive, involuntary movements
Correct Answer: A
Rationale: Behaviors that are repeated are symptomatic of obsessive-compulsive disorders. These behaviors, performed to reduce feelings of anxiety, often interfere with normal function and employment.
The nurse on the mental health unit is talking with a client with schizophrenia. Which of the following statements by the client would indicate that the client is experiencing a delusion of reference?
- A. Did you hear that voice? It told me to kill my parent.
- B. I need to get rid of the bugs that are crawling under my skin.
- C. The song on the radio is a message sent to me in secret code.
- D. I will not drink the tap water. The aliens are trying to poison me.
Correct Answer: C
Rationale: A delusion of reference involves believing neutral events or objects (e.g., a song on the radio) have personal significance or hidden messages (C). Auditory hallucinations (A) involve hearing voices, not reference. Tactile hallucinations (B) involve false sensations, and persecutory delusions (D) involve belief in harm without reference to neutral stimuli.
The doctor has ordered Nitrostat (nitroglycerine) sublingually for a client with angina. The client should be ordered to replenish his supply every:
- A. 6 months
- B. 3 months
- C. 12 months
- D. 18 months
Correct Answer: A
Rationale: Nitroglycerin loses potency after 6 months, requiring replacement to ensure efficacy for angina relief.
The nurse recognizes that which factors place a client at increased risk for falls? Select all that apply.
- A. Age of 50
- B. Diagnosis of ovarian cancer
- C. Lying pulse 80/min, standing pulse 110/min
- D. Osteoarthritis of knees
- E. Takes carbidopa/levodopa
- F. Uses a cane to ambulate
Correct Answer: C,D,E
Rationale: Orthostatic pulse change (C) indicates cardiovascular instability, increasing fall risk. Osteoarthritis of knees (D) impairs mobility and stability. Carbidopa/levodopa (E) for Parkinson’s can cause orthostatic hypotension or dyskinesia, heightening fall risk. Age 50 (A) is not a significant risk factor alone, ovarian cancer (B) is unrelated to falls, and cane use (F) reduces risk if used correctly.
The nurse should recognize that physical dependence is accompanied by what findings when alcohol consumption is first reduced or ended?
- A. Seizures
- B. Withdrawal
- C. Craving
- D. Marked tolerance
Correct Answer: B
Rationale: Withdrawal. Early withdrawal symptoms, including nausea and tremor, appear within hours of reducing alcohol intake.