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A nurse is assessing a client diagnosed with schizophrenia who has been treated with fluphenazine (Prolixin) for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?
- A. Sudden onset of high fever
- B. Twisting tongue movements
- C. Constant tapping of feet when sitting
- D. Shuffling gait
Correct Answer: B
Rationale: Twisting tongue movements are a classic sign of tardive dyskinesia from long-term antipsychotic use.
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A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Ritualistic behavior
- B. Short attention span
- C. Spinning a toy repetitively
- D. Consistent limit testing
- E. Delayed language development
Correct Answer: A,B,C,E
Rationale: The correct findings for a child with autism spectrum disorder are A, B, C, and E. A: Ritualistic behavior is common in children with ASD due to their need for predictability and routine. B: Short attention span is often seen in children with ASD, affecting their ability to focus on tasks. C: Spinning a toy repetitively is a stereotypical behavior associated with ASD, serving as a self-soothing mechanism. E: Delayed language development is a hallmark feature of ASD, impacting communication skills. These findings align with the core characteristics of ASD. Choices D and beyond are incorrect as they do not typically align with common manifestations of ASD in children.
Which of the following is a potential dietary recommendation for a client with iron-deficiency anemia?
- A. Limit intake of iron-rich foods to prevent iron overload
- B. Focus on consuming foods high in vitamin C to enhance iron absorption
- C. Avoid foods high in iron such as leafy greens and legumes
- D. Increase intake of iron-rich foods such as red meat and spinach
Correct Answer: B,D
Rationale: The correct answers are B and D. Answer B suggests focusing on consuming foods high in vitamin C to enhance iron absorption. Vitamin C helps increase the absorption of non-heme iron found in plant-based foods, which is important for individuals with iron-deficiency anemia. Answer D recommends increasing intake of iron-rich foods such as red meat and spinach. Red meat contains heme iron, which is more easily absorbed by the body compared to non-heme iron. Therefore, including both vitamin C-rich foods and heme iron sources in the diet can help improve iron levels in individuals with iron-deficiency anemia.
Incorrect choices:
A: Limiting intake of iron-rich foods would not be advisable for someone with iron-deficiency anemia.
C: Avoiding foods high in iron would worsen the condition of iron-deficiency anemia.
E, F, G: No information provided.
A client has made the decision to leave her alcoholic husband and reports feeling very depressed. Which of the following is a non-therapeutic statement by the nurse that demonstrates sympathy?
- A. You are feeling very depressed. I felt the same way when I decided to leave my husband.
- B. I can understand you are feeling depressed. It was a difficult decision. I'll sit with you.
- C. You seem depressed. It was a difficult decision to make. Would you like to talk about it?
- D. I know this is a difficult time for you. Would you like medication for anxiety?
Correct Answer: A
Rationale: The correct answer is A because the nurse is sharing her personal experience, which is not therapeutic as it shifts the focus from the client to the nurse's own experience. This can make the client feel unheard and invalidated. Choice B demonstrates empathy and offers support by acknowledging the client's feelings and offering to sit with them. Choice C also shows empathy and provides an opportunity for the client to talk. Choice D is non-therapeutic as it jumps to suggesting medication without exploring the client's emotions or needs.
A nurse is teaching a client who has septic shock about the development of disseminated intravascular coagulation (DIC). Which of the following statements should the nurse make?
- A. DIC is characterized by an elevated platelet count.
- B. DIC is caused by abnormal coagulation involving fibrinogen.
- C. DIC is controllable with lifelong heparin usage.
- D. DIC is a genetic disorder involving a vitamin K deficiency.
Correct Answer: B
Rationale: Correct Answer: B - DIC is caused by abnormal coagulation involving fibrinogen.
Rationale: DIC is a complex disorder characterized by widespread activation of coagulation leading to both excessive clot formation and consumption of clotting factors, including fibrinogen. This results in abnormal coagulation and fibrinolysis, leading to both bleeding and clotting throughout the body. Elevated platelet count is not a feature of DIC; instead, platelets are consumed in the process. Lifelong heparin usage is not a standard treatment for DIC, as it is a condition that requires specific management based on the underlying cause. DIC is not a genetic disorder but rather an acquired condition often triggered by severe infections, sepsis, trauma, or other critical illnesses. Vitamin K deficiency is associated with certain clotting factor deficiencies but is not the primary cause of DIC.
A nurse is admitting a client with a history of alcohol use disorder. The nurse is aware that which of the following are potential physical symptoms of alcohol withdrawal? (Select all that apply.)
- A. Seizures
- B. Tachycardia
- C. Hallucinations
- D. Tremors
- E. Hypotension
Correct Answer: A,B,C,D
Rationale: The correct answer is A, B, C, and D. Alcohol withdrawal can lead to seizures due to hyperexcitability of the nervous system. Tachycardia is common as alcohol withdrawal can cause increased heart rate and blood pressure. Hallucinations are possible due to disturbances in brain function. Tremors are a typical symptom of alcohol withdrawal, known as "the shakes." Choices E and F, hypotension and G, are not typically associated with alcohol withdrawal. In summary, the correct symptoms are related to central nervous system hyperactivity, while the incorrect choices are not commonly observed in alcohol withdrawal.