Nokea
A nurse in an emergency department completes an assessment on an adolescent client with conduct disorder. The client threatened suicide to a teacher at school. Which of the following statements should the nurse include in the assessment?
- A. Tell me about your siblings
- B. Tell me what kind of music you like
- C. Tell me how often you drink alcohol
- D. Tell me about your school schedule
Correct Answer: C
Rationale: The correct answer is C: 'Tell me how often you drink alcohol.' Alcohol use can exacerbate aggressive behaviors and is relevant for the assessment of suicide risk in adolescents with conduct disorders. Choices A, B, and D are unrelated to the assessment of suicide risk in this scenario and do not provide information that directly impacts the client's risk assessment.
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A nurse is providing discharge teaching to a client who has schizophrenia and is starting therapy with clozapine. Which of the following is the highest priority to report to the provider?
- A. Constipation
- B. Blurred vision
- C. Fever
- D. Dry mouth
Correct Answer: C
Rationale: The correct answer is C: Fever. Clozapine can cause agranulocytosis, a serious condition that leads to infections. Fever may indicate an underlying infection, a potentially life-threatening complication, and must be reported immediately to the provider for further evaluation and management.
Choice A (Constipation) is a common side effect of clozapine but is not as urgent as fever. Blurred vision (Choice B) and dry mouth (Choice D) are side effects of clozapine but are not indicative of a life-threatening condition like agranulocytosis.
A nurse is providing teaching for a client who has GERD. Which of the following assessment findings should the nurse expect to find?
- A. Shortness of breath
- B. Rebound tenderness
- C. Atypical chest pain
- D. Vomiting blood
Correct Answer: C
Rationale: The correct answer is C: Atypical chest pain. GERD often presents with atypical chest pain due to acid reflux, which can mimic the symptoms of cardiac conditions but is related to the esophagus. Shortness of breath (choice A) is not a typical assessment finding in GERD. Rebound tenderness (choice B) is associated with peritoneal inflammation, not GERD. Vomiting blood (choice D) is a severe symptom that may indicate esophageal damage but is not a common assessment finding in GERD.
A nurse is providing teaching to a client who has mild persistent asthma and has been prescribed montelukast. Which of the following statements should the nurse include in the teaching?
- A. This medication can be used to help manage asthma symptoms during an acute asthma attack
- B. This medication should be taken before exercise and physical activity
- C. This medication should be taken regularly as prescribed without discontinuing abruptly
- D. This medication helps decrease swelling and mucus production
Correct Answer: D
Rationale: Montelukast works as a leukotriene receptor antagonist, reducing inflammation and mucus production, which helps prevent asthma attacks but is not used for acute treatment. It is important for the client to understand that montelukast should be taken regularly to manage asthma symptoms and should not be abruptly discontinued. Taking the medication before exercise is not a typical instruction for montelukast.
A nurse is preparing to administer TPN with added fat supplements to a client who has malnutrition. Which of the following actions should the nurse take?
- A. Administer the TPN solution separately from 0.9% sodium chloride
- B. Check for an allergy to eggs
- C. Discuss the TPN solution with the client
- D. Monitor for hypoglycemia
Correct Answer: B
Rationale: The correct action for the nurse to take when preparing to administer TPN with fat supplements is to check for an allergy to eggs. The lipid emulsion in TPN often contains egg phospholipids, so screening for egg allergies is crucial to prevent any adverse reactions. Option A is incorrect because TPN should not be piggybacked with 0.9% sodium chloride to avoid any interactions or dilution of the TPN solution. Option C is incorrect as discussing the TPN solution with the client is not the priority when preparing to administer it. Option D is incorrect as monitoring for hypoglycemia, although important in TPN administration, is not specifically related to the addition of fat supplements.
A nurse is receiving a report on four clients. Which of the following clients should the nurse assess first?
- A. A client who has an ileal conduit and mucus in the pouch
- B. Client with arteriovenous fistula with additional vibration palpated
- C. A client with chronic kidney disease and cloudy dialysate outflow
- D. A client with transurethral resection of the prostate with red-tinged urine
Correct Answer: C
Rationale: The nurse should assess the client with chronic kidney disease and cloudy dialysate outflow first because cloudy dialysate outflow suggests peritonitis, a serious complication of peritoneal dialysis that requires immediate intervention. Assessing and addressing peritonitis promptly is crucial to prevent further complications and ensure the client's safety. Choices A, B, and D present important findings that require attention but are not as urgent as peritonitis, which can quickly escalate and endanger the client's health.