Nokea
A 20-year-old male has recently been diagnosed with schizophrenia. The nurse knows which of the following are classic signs and symptoms of this disorder? Select all that apply.
- A. social withdrawal
- B. agitation
- C. auditory hallucinations
- D. disorganized speech
- E. obsession with personal hygiene
Correct Answer: A,C,D
Rationale: Schizophrenia symptoms include social withdrawal, auditory hallucinations, and disorganized speech. Agitation may occur but is less specific, and obsession with hygiene is not typical.
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The nurse is reviewing a client's PRN pain medications. There is an order for acetaminophen 1,000 mg PO q4 hours as needed for pain. How should the nurse proceed?
- A. call the health care provider to clarify the order
- B. administer the medication as ordered if needed for pain
- C. give other PRN medications for pain and ignore the order
- D. avoid giving pain medication every 4 hours and give it every 6 hours
Correct Answer: B
Rationale: Acetaminophen 1,000 mg q4 hours PRN is within safe dosing (max 4,000 mg/day), so it can be administered as ordered.
A client with Addison's disease has been receiving glucocorticoid therapy. Which finding indicates a need for dosage adjustment?
- A. Dryness of the skin and mucus membranes
- B. Dizziness when rising to a standing position
- C. A weight gain of 6 pounds in the past week
- D. Difficulty in remaining asleep
Correct Answer: C
Rationale: A weight gain of 6 pounds in a week suggests fluid retention, indicating possible overdosage of glucocorticoids, requiring adjustment.
The nurse is caring for a client with epilepsy who is to receive Dilantin 100 mg IV push. The client has an IV of D51/2NS infusing at 100 mL/hr. When administering the Dilantin, the nurse should first:
- A. Obtain an ambu bag and put it at bedside
- B. Insert a 16 g IV catheter
- C. Flush the IV line with normal saline
- D. Premedicate with phenergan IV push
Correct Answer: C
Rationale: Dilantin is incompatible with dextrose solutions (D51/2NS), causing precipitation. Flushing with normal saline ensures compatibility and prevents complications.
When caring for the child with autistic disorder, the nurse should:
- A. Take the child to the playroom to be with peers
- B. Assign a consistent caregiver
- C. Place the child in a ward with other children
- D. Assign several staff members to provide care
Correct Answer: B
Rationale: A consistent caregiver provides stability and reduces anxiety in a child with autism.
The physician has ordered Vancocin (vancomycin) 500 mg IV every 6 hours for a client with MRSA. The medication should be administered:
- A. IV push
- B. Over 15 minutes
- C. Over 30 minutes
- D. Over 60 minutes
Correct Answer: D
Rationale: Vancomycin should be infused over at least 60 minutes to prevent adverse reactions such as red man syndrome.