Nokea
A female client with paranoid schizophrenia has been hearing negative voices and 'getting special messages from various sources,' which of the following interventions is most appropriate for the client's symptoms?
- A. Asking her to make simple decisions
- B. Being matter-of-fact with her
- C. Monitoring her reactions to television programs
- D. Reinforcing appropriate dress and hygiene
Correct Answer: B
Rationale: Being matter-of-fact helps ground a client with paranoid schizophrenia, reducing misinterpretations of reality. Decision-making, TV monitoring, or hygiene reinforcement are less directly related to auditory hallucinations.
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The nurse is caring for a client with a history of epilepsy who is prescribed valproic acid (Depakene). Which of the following laboratory tests should the nurse monitor?
- A. Liver function tests.
- B. Renal function tests.
- C. Complete blood count.
- D. Blood glucose levels.
Correct Answer: A
Rationale: Valproic acid can cause hepatotoxicity, requiring regular monitoring of liver function tests.
A client who has been taking diazepam (Valium) for 3 months for skeletal muscle spasms and the patient was a secret agent to the medication and the medication days ago because it was no longer helping him, but now he feels terrible. The nurse should assess the client for which of the following? Select all that apply.
- A. Insomnia.
- B. Euphoria.
- C. Bradycardia.
- D. Diaphoresis.
- E. Tremor.
- F. Vomiting.
Correct Answer: A, D, E, F
Rationale: Abrupt cessation of diazepam can cause withdrawal symptoms like insomnia, diaphoresis, tremor, and vomiting.
Which of the following is a priority nursing diagnosis for the client presenting with pelvic inflammatory disease?
- A. Imbalanced nutrition: Less than body requirements.
- B. Bathing/hygiene self-care deficit.
- C. Acute pain.
- D. Impaired skin integrity.
Correct Answer: C
Rationale: Acute pain is the priority diagnosis for pelvic inflammatory disease, as it is a hallmark symptom requiring immediate management.
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.
A client with a history of myocardial infarction is prescribed aspirin. What is the primary purpose of this medication?
- A. Reduce fever.
- B. Prevent platelet aggregation.
- C. Relieve chest pain.
- D. Lower cholesterol.
Correct Answer: B
Rationale: Aspirin prevents platelet aggregation, reducing the risk of thrombus formation in clients with a history of myocardial infarction.