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A dexamethasone-suppression test has been ordered for a client with severe depression. The purpose of the dexamethasone suppression test is to:
- A. Determine which social intervention will be best for the client
- B. Help diagnose the seriousness of the client's clinical symptoms
- C. Determine whether the client will benefit from electroconvulsive therapy
- D. Reverse the depressive symptoms the client is experiencing
Correct Answer: B
Rationale: The dexamethasone suppression test assesses cortisol suppression to evaluate hypothalamic-pituitary-adrenal axis dysfunction, aiding in diagnosing severe depression.
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A nurse is caring for a client with a myocardial infarction. The nurse recognizes that the most common complication in the client following a myocardial infarction is:
- A. Right ventricular hypertrophy
- B. Cardiac dysrhythmia
- C. Left ventricular hypertrophy
- D. Hyperkalemia
Correct Answer: B
Rationale: Cardiac dysrhythmias are the most common complication following a myocardial infarction due to ischemia affecting the heart's electrical conduction system, leading to arrhythmias like ventricular tachycardia or fibrillation.
The nurse working in an outpatient clinic is preparing to teach insulin injection to an elderly male client who is hard of hearing yet refuses to wear prescribed hearing aids. Which of the following communication strategies would be most appropriate for the nurse to use?
- A. speak in a high-pitched voice
- B. use sign language
- C. ensure the room.Concurrent is well lit
- D. refrain from touching the client
Correct Answer: C
Rationale: A well-lit room enhances visual cues, aiding communication for a client with hearing difficulties who relies on lip-reading or facial expressions.
The nurse is caring for a client after an open reduction to the left ulna. The client's left arm is in a plaster cast with an Ace wrap for reinforcement. Which intervention by the nurse can offer nonpharmacological comfort to this client?
- A. elevate the left arm on a pillow and apply an ice pack over the approximate location of the surgical incision
- B. call the physician and obtain an order for acetaminophen (Tylenol) 650 mg PO PRN q6 hours as needed for pain
- C. advise the client that if he starts to itch under the cast, he can use a wire coat hanger or an ink pen to gently scratch up under the cast
- D. perform range-of-motion exercises twice a shift, including bending the fingers, opening and closing the hand, and lifting the arm up to shoulder level
Correct Answer: A
Rationale: Elevation and ice reduce swelling and pain nonpharmacologically. Scratching under the cast risks skin damage, and excessive movement may disrupt healing.
A client admitted with gastroenteritis and a potassium level of 2.9 mEq/dL has been placed on telemetry. Which ECG finding would the nurse expect to find due to the client's potassium results?
- A. A depressed ST segment
- B. An elevated T wave
- C. An absent P wave
- D. A flattened QRS
Correct Answer: A
Rationale: Hypokalemia (2.9 mEq/dL) can cause a depressed ST segment, flattened T waves, and prominent U waves on ECG due to altered cardiac repolarization.
Which of the following examples represents parallel play?
- A. Jenny and Tommy share their toys.
- B. Jimmy plays with his car beside Mary, who is playing with her doll.
- C. Kevin plays a game of Scrabble with Kathy and Sue.
- D. Mary plays with a handheld game while sitting in her mother's lap.
Correct Answer: B
Rationale: Parallel play involves children playing side by side with similar toys but without direct interaction, as described in the scenario with Jimmy and Mary.