Nokea
A male client with an antisocial personality disorder is admitted to an inpatient mental health unit for multiple substance dependencies. When providing a history, the client justifies to the nurse his use of illicit drugs. Based on this pattern of behavior, this client's history is most likely to include which finding?
- A. Multiple convictions for misdemeanors and class B felonies.
- B. A history of stable employment
- C. Strong relationships with family members
- D. A pattern of seeking help when needed
Correct Answer: A
Rationale: The correct answer is A: Multiple convictions for misdemeanors and class B felonies. Clients with antisocial personality disorder often engage in behaviors that disregard societal rules and norms, leading to legal issues and criminal activities. This behavior is characteristic of individuals with antisocial personality disorder. Choices B, C, and D are incorrect because individuals with this disorder are less likely to have stable employment, strong family relationships, or seek help when needed due to their pattern of defiance and disregard for authority and rules.
You may also like to solve these questions
A female client reports that she drank a liter of a solution to cleanse her intestines but vomited immediately after. How many ml of fluid intake should the nurse document?
- A. 1000 ml
- B. 800 ml
- C. 760 ml
- D. 500 ml
Correct Answer: C
Rationale: The correct answer is 760 ml. One liter equals 1000 ml. As the client vomited immediately after drinking, she would have expelled approximately 240 ml (1 cup). Subtracting this from the initial intake of 1000 ml gives us 760 ml as the remaining fluid intake that should be documented. Choices A, B, and D are incorrect because they do not reflect the correct calculation of subtracting the amount vomited from the initial intake.
The nurse is assessing a client with left-sided heart failure. Which assessment finding requires immediate intervention?
- A. Jugular venous distention
- B. Shortness of breath
- C. Crackles in the lungs
- D. Peripheral edema
Correct Answer: C
Rationale: In a client with left-sided heart failure, crackles in the lungs are a critical assessment finding that necessitates immediate intervention. Crackles indicate pulmonary congestion, a sign of worsening heart failure that requires prompt attention to prevent respiratory distress. Jugular venous distention, shortness of breath, and peripheral edema are also common in heart failure, but crackles specifically point to pulmonary involvement and the urgent need for intervention.
A male client notifies the nurse that he feels short of breath and has chest pressure radiating down his left arm. A STAT 12-lead electrocardiogram (ECG) is obtained and shows ST segment elevation in leads II, III, aVF, and V4R. The nurse collects blood samples and gives a normal saline bolus. What action is most important for the nurse to implement?
- A. Obtain the results for STAT serum cardiac biomarkers.
- B. Assess for contraindications for thrombolytic therapy.
- C. Measure ST-segment height and waveform changes.
- D. Transfer for percutaneous coronary intervention (PCI).
Correct Answer: B
Rationale: Assessing for contraindications for thrombolytic therapy is crucial as it determines whether the client is a candidate for reperfusion therapy. In this scenario, the client is presenting with symptoms and ECG changes consistent with an acute myocardial infarction (MI). Thrombolytic therapy aims at restoring blood flow to the heart muscle, reducing the size of the infarct. However, it is essential to assess for contraindications such as recent surgery, active bleeding, or a history of stroke to avoid potential complications. Obtaining serum cardiac biomarkers or measuring ST-segment changes are important steps in the diagnosis of MI but are not as time-sensitive as assessing for contraindications to thrombolytic therapy. Transfer for percutaneous coronary intervention (PCI) is a definitive treatment for MI, but assessing for thrombolytic therapy eligibility takes precedence in this acute situation.
A client with a history of chronic kidney disease (CKD) is scheduled for a CT scan with contrast. Which laboratory value should the nurse review before the procedure?
- A. Serum creatinine
- B. Blood urea nitrogen (BUN)
- C. Serum potassium
- D. Serum glucose
Correct Answer: A
Rationale: The correct answer is A: Serum creatinine. Before a CT scan with contrast, the nurse should review the serum creatinine level. This is crucial in patients with CKD because contrast agents can potentially worsen kidney function and lead to contrast-induced nephropathy. Monitoring serum creatinine helps assess kidney function and determine the risk of complications. Choices B, C, and D are less relevant in this scenario. Blood urea nitrogen (BUN) is another marker of kidney function, but serum creatinine is a more specific indicator. Serum potassium levels are important in assessing electrolyte balance but are not directly related to the risk of contrast-induced nephropathy. Serum glucose levels are not typically a primary concern before a CT scan with contrast in a patient with CKD.
The nurse weighs a 6-month-old infant during a well-baby check-up and determines that the baby's weight has tripled compared to the birth weight of 7 pounds 8 ounces. The mother asks if the baby is gaining enough weight. What response should the nurse offer?
- A. Your baby is gaining weight right on schedule
- B. What food does your baby usually eat in a normal day?
- C. The baby is below the normal percentile for weight gain
- D. What was the baby's weight at the last well-baby check-up?
Correct Answer: A
Rationale: The correct answer is A: 'Your baby is gaining weight right on schedule.' Tripling of birth weight by 6 months is a normal growth pattern in infants, indicating appropriate weight gain and development. Choice B is unrelated to the question as it focuses on the baby's diet rather than addressing the weight gain concern. Choice C is incorrect as tripling the birth weight is considered a healthy growth pattern, not below normal percentile. Choice D is irrelevant to the mother's question about the adequacy of weight gain.