Nokea
A nurse in an acute mental health unit is admitting a client diagnosed with bipolar disorder. The nurse recognizes which of the following findings supports the admitting diagnosis of acute mania?
- A. The client responds to questions with disorganized speech.
- B. The client has lost interest in sexual relations.
- C. The client reports that voices are telling him to write a novel.
- D. The client's spouse reports that the client has recently gained weight.
Correct Answer: A
Rationale: The correct answer is A because responding to questions with disorganized speech is a common symptom of acute mania in bipolar disorder. This symptom is indicative of the manic phase, where individuals often exhibit pressured speech, flight of ideas, and tangential thinking. Choice B, loss of interest in sexual relations, is more associated with depression than mania. Choice C, hearing voices instructing to write a novel, is more suggestive of psychosis rather than mania. Choice D, weight gain, is not a specific symptom of acute mania.
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Which of the following is a risk factor for shaken baby syndrome?
- A. Low socioeconomic status
- B. Inadequate parental education
- C. Having multiple siblings
- D. Physical disability of the caregiver
Correct Answer: A
Rationale: The correct answer is A: Low socioeconomic status. Low socioeconomic status can lead to increased stress levels and lack of access to resources, increasing the likelihood of caregiver frustration and potential for shaken baby syndrome. Inadequate parental education (B) may contribute, but is not as directly linked. Having multiple siblings (C) and physical disability of the caregiver (D) are not direct risk factors for shaken baby syndrome.
A nurse is teaching a newly licensed nurse about heparin-induced thrombocytopenia. Which of the following risk factors for this disorder should the nurse include in the teaching?
- A. Systemic lupus erythematosus
- B. Placental abruption
- C. Heparin therapy for deep-vein thrombosis
- D. Warfarin therapy for atrial fibrillation
Correct Answer: C
Rationale: Rationale: Heparin-induced thrombocytopenia (HIT) is a rare but serious complication of heparin therapy, causing a drop in platelet count. The correct answer is C because heparin therapy for deep-vein thrombosis is a known risk factor for HIT. Systemic lupus erythematosus (choice A) is associated with other complications but not specifically HIT. Placental abruption (choice B) is a condition related to pregnancy complications. Warfarin therapy for atrial fibrillation (choice D) is not a risk factor for HIT. Therefore, the nurse should focus on heparin therapy as a significant risk factor in HIT education.
A male client is admitted to the unit with a possible diagnosis of delirium. Which statement by the client's wife best supports the diagnosis?
- A. Since his mother died, he has not been feeling well.
- B. My husband just didn't seem to know what he was doing. He has been forgetful for years.
- C. The changes in his behavior came on so quickly! I wasn't sure what was happening.
- D. This is supposed to happen when you get old, right?
Correct Answer: C
Rationale: The correct answer is C because delirium is characterized by a rapid onset of confusion, changes in behavior, and altered mental status. The wife's statement about the changes in behavior coming on quickly aligns with this key characteristic of delirium.
Choice A is incorrect because the client's feelings after his mother's death are not necessarily related to delirium. Choice B is incorrect because long-term forgetfulness is more indicative of dementia rather than delirium. Choice D is incorrect because delirium is not a normal part of aging.
A nurse is planning care for a client who is postoperative following a thyroidectomy. Which of the following interventions should the nurse include in the plan?
- A. Hyperextend the client's neck.
- B. Instruct the client to deep breathe every 4 hr.
- C. Place the head of the client's bed in the flat position.
- D. Check the client's voice every 2 hr.
Correct Answer: B,D
Rationale: The correct answers are B and D. Instructing the client to deep breathe every 4 hours helps prevent respiratory complications post-thyroidectomy. Checking the client's voice every 2 hours is important to monitor for vocal cord damage, a potential complication. Choice A is incorrect as hyperextending the client's neck can put strain on the surgical site. Choice C is incorrect as the head of the bed should be elevated to reduce swelling and promote drainage.
A nurse is caring for a client who has sickle cell anemia. The client asks,Why do I feel so tired and fatigued all of the time? Which of the following information should the nurse provide?
- A. You have had a gastrointestinal bleed.
- B. You have fewer red blood cells.
- C. You have an autoimmune disease.
- D. You have a low ferritin level.
Correct Answer: B
Rationale: Correct Answer: B - You have fewer red blood cells.
Rationale: In sickle cell anemia, the abnormal hemoglobin causes red blood cells to become rigid, sticky, and crescent-shaped, leading to decreased oxygen delivery. This results in anemia, leading to fatigue and tiredness. Choice A is incorrect as it does not directly relate to the pathophysiology of sickle cell anemia. Choice C is unrelated to the client's symptoms. Choice D is not specific to the underlying cause of fatigue in sickle cell anemia.