Nokea
A client with schizophrenia is responding well to risperidone (Risperdal) and is no longer psychotic. After teaching the client about managing his illness, which of the following statements reflects a need for further education?
- A. I just don't know if I can afford to keep taking medicines every day
- B. When my thoughts start racing, I know I need to relax more
- C. I can name the side effects of Risperdal, but I'm not having any
- D. I don't listen to my mom's religious beliefs about not using medicines
Correct Answer: A
Rationale: Concern about affording daily medication suggests a need for further education on resources or adherence strategies, as non-adherence risks relapse. Other statements reflect appropriate understanding.
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A client with a history of epilepsy is prescribed phenobarbital. The nurse should monitor the client for which of the following side effects?
- A. Drowsiness.
- B. Hypertension.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: A
Rationale: Phenobarbital commonly causes drowsiness, which the nurse should monitor in clients with epilepsy.
As the nurse in a primary care clinic, which cultural concern would you integrate into your psychological assessments of your clients?
- A. The concern related to the client's cultural reluctance to report psychological symptoms because of some possible culturally based stigma associated with psychiatric mental health disorders
- B. Concerns revolving around the lack of financial and health insurance resources to pay for psychological care
- C. Concerns related to the compliance with psychological treatment regimens because of the client's lack of social support systems
- D. The concern related to the culturally based client apathy about nursing care and nursing assessments
Correct Answer: A
Rationale: Cultural stigma around mental health can significantly impact clients' willingness to report psychological symptoms, making it a critical consideration in assessments.
Which nursing action is most essential for the hospitalized client with a new tracheostomy?
- A. Decrease secretions
- B. Provide client teaching regarding tracheostomy care
- C. Relieve anxiety related to the tracheostomy
- D. Maintain a patent airway
Correct Answer: D
Rationale: Maintaining a patent airway is the most critical action for a client with a new tracheostomy to ensure adequate oxygenation. Other actions are important but secondary to airway patency.
A 24-year-old client has been diagnosed with acute osteomyelitis in the left leg. He complains of acute pain in the leg that intensifies when he moves it. The client has a temperature of 101°F (38.3°C) and a reddened, warm area in the midcalf region over the shaft of the tibia. Based on this information, which of the following nursing diagnoses would be most appropriate for this client?
- A. Grieving related to possible left lower leg amputation.
- B. Activity intolerance related to severe left leg pain.
- C. A disturbed body image related to left leg swelling and inflammation.
- D. Deficient fluid volume related to elevated temperature of 101°F (38.3°C).
Correct Answer: B
Rationale: Activity intolerance due to severe pain is the most appropriate diagnosis, as pain limits mobility. Amputation is not indicated, body image is secondary, and fever does not directly cause fluid volume deficit.
A nurse notices that a newborn has a swelling in the scrotum. The nurse should interpret this as indicative of hydrocele if which of the following occurs?
- A. The swollen bulge can be reduced.
- B. The increase in scrotal size is bilateral.
- C. The scrotal sac can be transilluminated.
- D. The bulge appears during crying.
Correct Answer: C
Rationale: Transillumination of the scrotal sac indicates fluid, characteristic of a hydrocele, a common newborn condition.