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A nurse is assessing a client who has been taking clozapine for 3 months. Which of the following findings should the nurse report to the provider immediately?
- A. Constipation
- B. Sore throat
- C. Dry mouth
- D. Drowsiness
Correct Answer: B
Rationale: The correct answer is B: Sore throat. Clozapine can cause agranulocytosis, a serious condition characterized by a low white blood cell count, which can manifest as sore throat, fever, or flu-like symptoms. Immediate reporting is crucial to monitor for potential complications. Constipation (A), dry mouth (C), and drowsiness (D) are common side effects of clozapine but do not require immediate reporting unless severe.
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A nurse is assessing a client who has histrionic personality disorder. Which of the following findings should the nurse expect?
- A. Lack of remorse
- B. Attention seeking
- C. Splitting of staff
- D. Identity disturbance
Correct Answer: B
Rationale: The correct answer is B: Attention seeking. In histrionic personality disorder, individuals often seek attention by being overly dramatic, seductive, or provocative. This behavior is a key characteristic of the disorder. Lack of remorse (A) is more indicative of antisocial personality disorder. Splitting of staff (C) is more commonly associated with borderline personality disorder. Identity disturbance (D) is a feature of borderline personality disorder as well. In summary, attention seeking behavior is a hallmark trait of histrionic personality disorder, making choice B the correct answer in this scenario.
A nurse is giving a presentation about intimate partner abuse for a community group. Which of the following statements by a group member indicates understanding of the teaching?
- A. Survivors of abuse often feel guilty
- B. Abusers often have high self-esteem
- C. The honeymoon stage of violence usually gets longer over time
- D. As abuse continues, victims become more determined to be independent
Correct Answer: A
Rationale: Correct Answer: A: Survivors of abuse often feel guilty
Rationale: This statement indicates understanding of the psychological impact of intimate partner abuse. Guilt is a common emotion experienced by survivors due to manipulation and blame from the abuser. It reflects the internalized self-blame and shame that many survivors struggle with.
Summary of other choices:
B: Abusers often have high self-esteem - Incorrect. Abusers typically have low self-esteem and use abuse as a way to exert power and control.
C: The honeymoon stage of violence usually gets longer over time - Incorrect. The honeymoon phase tends to decrease over time as abuse cycles escalate.
D: As abuse continues, victims become more determined to be independent - Incorrect. Victims often experience increased isolation and dependency on the abuser.
A nurse is planning care for a client who has bipolar disorder. The client reports not sleeping for 3 days and is exhibiting a euphoric mood. The nurse should identify which of the following as the priority intervention.
- A. Secure the client’s valuable possessions
- B. Limit loud noises in the client’s environment
- C. Encourage the client to participate in structured solitary activities
- D. Provide high calorie snacks to the client
Correct Answer: D
Rationale: The correct answer is D: Provide high calorie snacks to the client. The priority intervention in this scenario is to address the client's lack of sleep and increased energy levels due to mania. Providing high-calorie snacks can help stabilize blood sugar levels and provide sustained energy, potentially aiding in promoting sleep. The other choices are incorrect because securing valuable possessions, limiting loud noises, and encouraging solitary activities do not directly address the immediate need to manage the client's symptoms related to lack of sleep and euphoria.
A nurse is caring for a client with Alzheimer’s disease. Which of the following actions should the nurse take?
- A. Seat the client at a dining table with six or more residents
- B. Provide the client with several choices for meal selection
- C. Give complete directions before starting client care
- D. Use symbols to assist the client in locating rooms
Correct Answer: D
Rationale: The correct answer is D. Using symbols to assist the client in locating rooms is beneficial for a client with Alzheimer's as they may have difficulty remembering locations. Symbols can serve as visual cues to help them navigate and reduce confusion. A: Seating the client at a dining table with multiple residents may be overwhelming and lead to agitation. B: Providing several meal choices can be confusing and increase indecision for someone with Alzheimer's. C: Giving complete directions all at once may be too much information for the client to process. Instead, simple and clear instructions are more effective.
A nurse is reviewing the laboratory results on an adolescent who has anorexia nervosa. Which of the following findings should the nurse expect?
- A. Blood glucose 100 mg/dL
- B. T4 11 mcg/dL
- C. Potassium 3.7 mEq/L
- D. Hgb 10 g/dL
Correct Answer: D
Rationale: The correct answer is D: Hgb 10 g/dL. In an adolescent with anorexia nervosa, low hemoglobin (Hgb) levels are expected due to malnutrition and inadequate intake of essential nutrients. Anorexia nervosa can lead to a deficiency in essential nutrients such as iron, which can result in anemia and low Hgb levels. This is a common finding in individuals with anorexia nervosa.
Blood glucose of 100 mg/dL (choice A) is within the normal range and not specific to anorexia nervosa. T4 of 11 mcg/dL (choice B) is also within the normal range and not typically affected by anorexia nervosa. Potassium of 3.7 mEq/L (choice C) is within the normal range and not a common finding in anorexia nervosa. Therefore, the correct answer is D as it is a common laboratory finding associated with anorexia nervosa.