Nokea
A nurse is admitting a client who has schizophrenia. The client state nurse to state?"I'm hearing voices. Which of the following responses is the priority for the nurse to state"
- A. What are the voices telling you?
- B. I realize the voices are real to you, but I don't hear anything.â€
- C. Have you taken your medication today?â€
- D. How long have you been hearing the voices?
Correct Answer: A
Rationale: The correct answer is A: "What are the voices telling you?" This response shows active listening and encourages the client to express their thoughts, helping the nurse assess the content and potential danger of the voices. Choice B dismisses the client's experience, choice C focuses on medication compliance rather than immediate safety, and choice D is relevant but does not address the immediate concern.
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Which of the following actions is the priority for the nurse to take?
- A. Evaluate the client for orthostatic hypotension.
- B. Monitor the client's urine output.
- C. Obtain the client's laboratory results.
- D. Check the client for nasal congestion
Correct Answer: A
Rationale: Orthostatic hypotension is a potential adverse effect of valsartan overdose.
A nurse is providing teaching to a client who has a new prescription for enoxaparin. Which of the following medications for pain relief should the nurse include in the teaching that can be taken concurrently with enoxaparin?
- A. Ibuprofen
- B. Naproxen sodium
- C. Acetaminophen
- D. Aspirin
Correct Answer: C
Rationale: Rationale: Acetaminophen is the appropriate pain relief option to be taken concurrently with enoxaparin because it does not interfere with platelet aggregation or clotting factors, unlike other options. Ibuprofen, naproxen sodium, and aspirin are nonsteroidal anti-inflammatory drugs (NSAIDs) which can increase the risk of bleeding when taken with enoxaparin. Acetaminophen, on the other hand, does not have the same effect on platelet function, making it a safer choice for pain relief in patients taking enoxaparin.
Which of the following findings should the nurse expect?
- A. The client is oriented times three
- B. The client opens eyes to sound.
- C. The client is unable to obey commands.
- D. The client withdraws from pain
Correct Answer: A
Rationale: The correct answer is A: The client is oriented times three. This indicates that the client is alert and aware of person, place, and time. This finding is crucial in assessing the client's mental status and cognitive function. Opening eyes to sound (B) is a basic response but does not indicate orientation. Inability to obey commands (C) suggests altered mental status. Withdrawing from pain (D) may indicate a physical reflex rather than cognitive function. Overall, being oriented times three is the most comprehensive assessment of mental alertness and cognitive function.
Which of the following Instructions should the nurse include?
- A. Remain on bed rest for 24 hours following the procedure.
- B. Participate in range-of-motion exercises.
- C. Use an incentive spirometer every 4 hours.
- D. Place a pillow under your knees while in bed.
Correct Answer: B
Rationale: The correct answer is B: Participate in range-of-motion exercises. This instruction is important to prevent complications such as blood clots and muscle stiffness post-procedure. Range-of-motion exercises help maintain joint flexibility and circulation. Choice A is incorrect as prolonged bed rest can increase the risk of blood clots. Choice C is important but not as crucial immediately post-procedure compared to mobilizing joints. Choice D is a comfort measure and does not have direct implications for post-procedure complications.
Which of the following findings should the nurse expect?
- A. Head circumference exceeds chest circumference
- B. Palpable fontanels
- C. Natural loss of deciduous teeth
- D. Nontender, protruding abdomen
Correct Answer: D
Rationale: The correct answer is D: Nontender, protruding abdomen. This finding is expected in a child with kwashiorkor, a form of severe protein-energy malnutrition. The nontender, protruding abdomen is due to fluid accumulation in the abdomen (ascites) and the lack of muscle mass. This is a key characteristic of kwashiorkor. The other choices are incorrect because: A) Head circumference exceeding chest circumference is not a typical finding in children; B) Fontanels should be soft and flat in infants, not palpable; C) Natural loss of deciduous teeth occurs around age 6-12 years, not in infancy.