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A client presented herself to the mental health center, describing the following symptoms: a weight loss of 20 lb in the past 2 months, difficulty concentrating, repeated absences from work due to 'fatigue,' and not wanting to get dressed in the morning. She leaves her recorded message on her telephone and has lost interest in answering the phone or doorbell. The nurse's assessment of her behavior would most likely be:
- A. Deep depression
- B. Psychotic depression
- C. Severe anxiety
- D. Severe depression
Correct Answer: D
Rationale: Although the client was able to bring herself to the mental health center, the extent of her weight loss and the interference of symptoms with activities of daily living indicate that she is severely depressed.
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The nurse is caring for a client with a history of chronic kidney disease. Which dietary restriction is most important?
- A. Low potassium
- B. Low calcium
- C. Low magnesium
- D. Low iron
Correct Answer: A
Rationale: Chronic kidney disease impairs potassium excretion, risking hyperkalemia, which can cause arrhythmias. Low potassium diets are critical. Calcium, magnesium, and iron are less commonly restricted.
The client has an order for sliding scale insulin at 1900 hours and Lantus (glargine) insulin at the same hour. The nurse should:
- A. Administer the two medications together.
- B. Administer the two medications in two injections.
- C. Draw up the Lantus insulin and then the regular insulin and administer them together.
- D. Contact the doctor because these medications should not be given to the same client.
Correct Answer: B
Rationale: Lantus (glargine) is a long-acting insulin and should not be mixed with short-acting sliding scale insulin (e.g. regular insulin) due to differing pharmacokinetics. Administering them in separate injections ensures proper action profiles.
The nurse is caring for a client with a suspected stroke. Which assessment finding is most concerning?
- A. Mild headache
- B. Unilateral facial droop
- C. Slight dizziness
- D. Fatigue
Correct Answer: B
Rationale: Unilateral facial droop is a classic sign of stroke, indicating neurological deficit and requiring urgent evaluation. Headache (A), dizziness (C), and fatigue (D) are less specific.
The client is admitted with a diagnosis of postpartum endometritis. Which symptom is most characteristic?
- A. Foul-smelling lochia
- B. Painless vaginal bleeding
- C. Fetal distress
- D. Maternal hypotension
Correct Answer: A
Rationale: Postpartum endometritis causes foul-smelling lochia due to uterine infection. Painless bleeding suggests other causes fetal distress is irrelevant postpartum and hypotension occurs only in severe cases.
A 19-year-old primigravida is admitted to the labor and delivery suite of the hospital. Her husband is accompanying her. The couple tells the nurse that this is the first hospital admission for her. The client's vaginal exam indicates she is 3 cm dilated, 80% effaced, and at -0 station. Based on the vaginal exam, she is in:
- A. Stage 2, latent phase
- B. Stage 1, active phase
- C. Stage 3, transition phase
- D. Stage 1, latent phase
Correct Answer: D
Rationale: The second stage of labor is from full cervical dilation through birth of the baby. The three phases of this stage include latency or resting, descent, and final transition. The client is less than fully dilated so she is not in stage 2. The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor. The third stage of labor is from the birth of the baby until the delivery of the placenta. The client is less than fully dilated. The first stage of labor begins with regular uterine contractions and continues until the woman is 10 cm dilated. The three phases of this stage include the early or latent phase (0-3 cm), the active phase (4-7 cm), and the transitional phase (7-10 cm). The client is <4 cm dilated so she is in the latent phase of the first stage of labor.