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A client with severe major depression states, 'My heart has stopped and my blood is black ash.' The nurse interprets this statement to be evidence of which of the following?
- A. Hallucination.
- B. Illusion.
- C. Delusion.
- D. Paranoia.
Correct Answer: C
Rationale: The client's statement reflects a false, fixed belief that is not based in reality, which is characteristic of a delusion. Hallucinations involve sensory perceptions, illusions are misinterpretations of stimuli, and paranoia involves suspicion, none of which fit this scenario.
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A client with a history of heart failure is prescribed digoxin (Lanoxin). The nurse should instruct the client to:
- A. Report signs of toxicity.
- B. Take the medication with meals.
- C. Avoid potassium-rich foods.
- D. Stop the medication if pulse is above 100.
Correct Answer: A
Rationale: Reporting signs of digoxin toxicity (e.g., nausea, visual changes) is critical.
A client with pancreatitis is admitted with severe abdominal pain. Which position should the nurse encourage to reduce discomfort?
- A. Supine with legs elevated
- B. Side-lying with knees flexed
- C. Prone with a pillow under the abdomen
- D. Sitting upright
Correct Answer: B
Rationale: Side-lying with knees flexed reduces tension on the abdominal muscles and pancreas, helping to alleviate pain in pancreatitis.
A 5-year-old child is admitted with a fever and rash. The nurse suspects scarlet fever. Which assessment finding supports this diagnosis?
- A. Strawberry tongue
- B. Koplik spots
- C. Vesicular rash
- D. Pustules on the trunk
Correct Answer: A
Rationale: Strawberry tongue is a characteristic sign of scarlet fever, caused by group A Streptococcus, aiding in diagnosis confirmation.
The nurse providing care to a client with a leg fracture ensures that which intervention is first implemented before the fracture is reduced in the casting room?
- A. Obtaining an anesthesia consent
- B. Administering an opioid analgesic
- C. Notifying the operating room staff
- D. Obtaining an informed consent for treatment
Correct Answer: D
Rationale: Before a fracture is reduced, an informed consent for treatment is needed. The nurse should reinforce explanations according to the client's needs and ability to understand. Administration of anesthesia would only be done in the operating room for open reduction of fractures. Closed reductions may be done in the emergency department without anesthesia. An analgesic would be administered as prescribed because the procedure is painful, but the informed consent form must be obtained before administering the medication.
The nurse is assessing a teenage girl. According to the fi gure below, the nurse should note that the girl has:
- A. Kyphosis.
- B. Arthritis.
- C. Developmental dysplasia of the hip.
- D. Scoliosis.
Correct Answer: D
Rationale: The teenage girl has scoliosis, the lateral deviation of the spine. Kyphosis is noted by a forward curvature of the shoulders. Arthritis is diagnosed by radiographs. Hip dysplasia is noted in older children by pain, but is usually diagnosed before the child walks by noting excessive gluteal folds and limited hip abduction.