Nokea
A 17-year-old adolescent, diagnosed with schizophrenia, is admitted by the nurse to a psychiatric facility. Which behaviors would characterize this diagnosis? Select all that apply.
- A. flat affect
- B. fast speech pattern
- C. hallucinations
- D. feeling energized
Correct Answer: A,C
Rationale: Flat affect and hallucinations are hallmark symptoms of schizophrenia. Fast speech or feeling energized may occur but are not specific to this diagnosis.
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An 80-year-old man with a decubitus ulcer has just been admitted to the floor. Upon assessment of the wound, the nurse notes that an area of skin under the wound extends and creates another opening in the skin 4 centimeters away. She would chart this as
- A. tunneling.
- B. dehiscence.
- C. undermining.
- D. evisceration.
Correct Answer: A
Rationale: Tunneling is a narrow channel extending from a wound, creating another skin opening, as described. Undermining involves a wider area under intact skin, dehiscence is wound separation, and evisceration is organ protrusion.
The nurse has just admitted a client with emphysema. Arterial blood gas results indicate hypoxia. Which physician prescription would the nurse implement for the best improvement in the client's hypoxia?
- A. Elevate the head of the bed 45°
- B. Encourage diaphragmatic breathing
- C. Initiate an Alupent nebulizer treatment
- D. Start Oâ‚‚ at 2 L/min
Correct Answer: D
Rationale: Low-flow oxygen (2 L/min) directly addresses hypoxia in emphysema by improving arterial oxygen levels, making it the most effective intervention.
The physician has discussed the need for medication with the parents of an infant with congenital hypothyroidism. The nurse can reinforce the physician's teaching by telling the parents that:
- A. The medication will be needed only during times of rapid growth.
- B. The medication will be needed throughout the child's lifetime.
- C. The medication schedule can be arranged to allow for drug holidays.
- D. The medication is given one time daily every other day.
Correct Answer: B
Rationale: Congenital hypothyroidism requires lifelong thyroid hormone replacement therapy to maintain normal metabolism and development.
The nurse is performing an admission for a client recovering from a stroke. Medication history reveals the drug clopidogrel (Plavix). Which clinical manifestation alerts the nurse to an adverse effect of this drug?
- A. Epistaxis
- B. Abdominal distention
- C. Nausea
- D. Hyperactivity
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet drug, increases bleeding risk. Epistaxis (nosebleed) is a significant adverse effect requiring attention.
Following femoral catheterization for percutaneous coronary intervention (PCI), the client has increasing pain in the catheterization site, and the nurse notes visible edema and induration surrounding the site. The nurse suspects a hematoma and notifies the physician. Which of the following interventions does the nurse anticipate? Select all that apply.
- A. Apply pressure to the site.
- B. Mark margins of edematous, indurated area.
- C. Monitor hemoglobin and hematocrit.
- D. Maintain bedrest.
- E. Administration of clotting factors.
Correct Answer: A,B,C,D
Rationale: Hematoma management includes applying pressure (A), marking edema (B), monitoring hemoglobin/hematocrit (C), and maintaining bedrest (D). Clotting factors (E) are not typically needed.