Nokea
A male client tells the nurse that he has an IQ of 400+ and is a genius and an inventor. He also reports that he is married to a female movie star and thinks that his brother wants a sexual relationship with her. Which is the priority nursing problem for admission to the psychiatric unit?
- A. Compromised family coping.
- B. Ineffective sexual patterns.
- C. Impaired environmental interpretation.
- D. Disturbed sensory perception.
Correct Answer: D
Rationale: Delusional beliefs indicate disturbed sensory perception, the priority problem requiring psychiatric evaluation.
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The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?
- A. Sweet potatoes.
- B. Spinach salad.
- C. Bananas.
- D. Fish.
Correct Answer: B
Rationale: Spinach is high in oxalates, contributing to calcium oxalate stone formation. Sweet potatoes, bananas, and fish are generally safe.
A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease-related?
- A. Ecchymotic blood accumulations.
- B. Evidence of patches of lost hair.
- C. Episodic complaints of pruritus.
- D. Erythema of the localized lesions.
Correct Answer: A
Rationale: Ecchymotic blood accumulations (bruises) suggest trauma or physical manipulation, indicating non-disease-related hair loss. Patches of hair loss, pruritus, or erythema could be associated with medical conditions like alopecia or inflammation.
History and Physical
Initial vital signs
The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and was recently diagnosed with end-stage renal disease (ERSD). She has been placed on hemodialysis three times a week for one month. She presents to the emergency department (ED) with fatigue, generalized weakness, muscle cramps, tingling sensation in arms and legs, and lightheadedness following 3 days of illness during which her husband reports she has complained of nausea and had poor appetite and was not able to go for her scheduled dialysis 2
Based on the client's subjective and objectives data, the nurse recognizes that she is having signs and symptoms of a sinus tachycardiahyperkalemiahypermagnesemiahypokalemia.
- A. Sinus tachycardia
- B. Hyperkalemia
- C. Hypermagnesemia
- D. Hypokalemia
Correct Answer: B
Rationale: The client's history of ESRD, missed dialysis, and symptoms (muscle cramps, tingling, weakness) suggest hyperkalemia, which can cause cardiac arrhythmias like sinus tachycardia. Other options are less consistent with the clinical picture.
When responding to a call light, the nurse finds a client with aggressive behaviors pacing, and restless in the room. The client shouts, 'What took you so long to get in here!' Which action should the nurse implement?
- A. Request backup from the staff.
- B. Stand in the doorway.
- C. Provide for personal space.
- D. Encourage the client to sit down.
Correct Answer: C
Rationale: Providing personal space reduces the perception of threat, helping de-escalate agitation safely.
The nurse is caring for a client who is experiencing extreme sadness after the passing of a companion of 30 years. The client describes not being able to think of other things and finds it difficult to control emotions. Which action should the nurse take first?
- A. Explore changes in life that have occurred after the loss.
- B. Suggest the need for a psychiatric consultation.
- C. Offer a referral to pastoral counseling.
- D. Encourage attending a local support group.
Correct Answer: A
Rationale: Exploring life changes post-loss helps assess the client's grief and tailor interventions, making it the priority action.