Nokea
A 25-year-old man is in an acute manic episode. The nurse knows that which client behavior would be MOST characteristic of mania?
- A. Agitation, grandiose delusions, euphoria, difficulty concentrating.
- B. Difficulty in decision-making, preoccupation with self, distorted perceptions.
- C. Paranoia, hallucinations, disturbed thought processes, hypervigilance.
- D. Fear of going crazy, somatic complaints, difficulties with intimacy, increased anxiety.
Correct Answer: A
Rationale: characteristic behaviors associated with an acute manic episode include agitation, grandiose delusions, euphoria, and concentration problems; mania is a mood of extreme euphoria and is manifested by more extreme levels of behavior
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A client is admitted with irritable bowel syndrome.
The nurse would anticipate the client's history to reflect which of the following?
- A. Pattern of alternating diarrhea and constipation.
- B. Chronic diarrhea stools occurring 10-12 times per day.
- C. Diarrhea and vomiting with severe abdominal distention.
- D. Bloody stools with increased cramping after eating.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-condition is often called spastic bowel disease; no inflammation is present (2) refers to inflammatory bowel disease such as ulcerative colitis or Crohn's disease (3) refers to inflammatory bowel disease such as ulcerative colitis or Crohn's disease (4) bloody stools do not occur
The physician has ordered a low-magnesium diet for a client with end-stage renal failure. Which of the following diet selections should be removed from the client's meal tray?
- A. Fruit compote
- B. Spinach salad
- C. Baked potato
- D. Custard
Correct Answer: B
Rationale: Spinach is high in magnesium, which should be restricted in end-stage renal failure due to impaired excretion. Fruit compote , baked potato , and custard are lower in magnesium.
The nurse is teaching a client with a new diagnosis of epilepsy about lamotrigine (Lamictal). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice
- B. Report any skin rash
- C. Stop the medication if seizures stop
- D. Avoid regular blood Test s
Correct Answer: B
Rationale: A skin rash may indicate Stevens-Johnson syndrome, a serious lamotrigine side effect. Options A, C, and D are incorrect: grapefruit juice is irrelevant, stopping the medication risks seizures, and blood Test s are needed.
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin glargine (Lantus) 20 units subcutaneously at bedtime. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose of 100 mg/dL.
- B. Heart rate of 80 bpm.
- C. Sweating and irritability.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: C
Rationale: Sweating and irritability indicate hypoglycemia, a serious complication of insulin glargine, requiring immediate treatment with carbohydrates. Options A, B, and D are normal: glucose 100 mg/dL, heart rate 80 bpm, and blood pressure 120/80 mmHg indicate stability.
A child in the waiting room who can walk up and down steps, has a steady gait, can stand on one foot momentarily, and jumps with both feet.
The nurse identifies the child's chronological age to be
- A. 1 year old.
- B. 2 years old.
- C. 3 years old.
- D. 5 years old.
Correct Answer: C
Rationale: Strategy: Picture the child at each age. (1) unable to walk up and down stairs with hand held until 18 months (2) unable to jump until 30 months (3) correct-able to jump with both feet and stand on one foot momentarily at 30 months (4) behaviors are seen in younger child