Nokea
A client continually repeats phrases that others have just said. The nurse recognizes this behavior as
- A. Autistic
- B. Echopraxis
- C. Echolalia
- D. Catatonic
Correct Answer: C
Rationale: Echolalia is repeating words or phrases heard before, often seen in certain psychiatric or developmental conditions.
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The nurse is caring for a client who has a prescription for ampicillin 1.5 g IV in 100 mL of 0.9% sodium chloride to be administered over 30 minutes. The nurse has tubing with a drop factor of 15 available. How many gtts/min should the client receive? Record your answer using a whole number.
Correct Answer: 50
Rationale: Flow rate = (100 mL / 30 min) x (15 gtts/mL) = 50 gtts/min (A).
The nurse is caring for an 87 year-old client with urinary retention. Which finding should be reported immediately?
- A. Fecal impaction
- B. Infrequent voiding
- C. Stress incontinence
- D. Burning with urination
Correct Answer: A
Rationale: Fecal impaction. The nurse should report fecal impaction or constipation which can cause obstruction of the bladder outlet. Bladder outlet obstruction is a common cause of urine retention in the elderly.
The nurse administers subcutaneous insulin lispro at 0730 to a client as prescribed and the client consumes breakfast 30 minutes later. At what time is the client at highest risk for experiencing insulin-related hypoglycemia?
- A. 830
- B. 1100
- C. 1330
- D. 1500
Correct Answer: B
Rationale: Insulin lispro peaks 1-2 hours after administration, so 1100 (B), about 3.5 hours post-injection, is the highest risk time for hypoglycemia.
While planning care for a 2 year-old hospitalized child, which situation would the nurse expect to most likely affect the behavior?
- A. Strange bed and surroundings
- B. Separation from parents
- C. Presence of other toddlers
- D. Unfamiliar toys and games
Correct Answer: B
Rationale: Separation from parents. Separation anxiety is the greatest stress for a toddler during hospitalization.
A client receiving aminophylline IV complains of feeling nervous and shaky. The nurse is aware that these are symptoms of:
- A. CNS depression that accompanies xanthine derivatives
- B. CNS stimulation that sometimes accompanies xanthine derivatives
- C. The anticholinergic effects of aminophylline
- D. Cardiovascular depression that can accompany xanthine derivatives
Correct Answer: B
Rationale: Aminophylline, a xanthine derivative, can cause CNS stimulation, leading to nervousness and shakiness. It does not typically cause CNS or cardiovascular depression or anticholinergic effects.