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A nurse is assessing a client who is experiencing a thyroid storm. Which of the following findings should the nurse anticipate?
- A. Coma
- B. Hypothermia
- C. Tachycardia
- D. Fruity smelling breath
Correct Answer: C
Rationale: The correct answer is C: Tachycardia. In a thyroid storm, there is an excessive release of thyroid hormones leading to severe symptoms. Tachycardia is a hallmark sign due to the increased metabolic rate and sympathetic response. Coma (A) is a severe complication but not an anticipated finding. Hypothermia (B) is incorrect as the body temperature is typically elevated. Fruity smelling breath (D) is more indicative of diabetic ketoacidosis, not thyroid storm.
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Claudette, the nurse, is conducting group therapy with a group of clients. Which of the following statements made by a client is an example of aggressive communication
- A. I feel angry when you leave me.
- B. I wish you would not make me angry.
- C. It makes me angry when you interrupt me.
- D. You'd better listen to me.
Correct Answer: D
Rationale: The correct answer is D because it is an example of aggressive communication. The statement "You'd better listen to me" is forceful, directive, and implies a threat if the listener does not comply. This type of communication lacks respect for the other person's feelings and boundaries. In contrast, choices A, B, and C express personal feelings and thoughts without being demanding or confrontational. Choice A uses "I feel" to express emotions, choice B expresses a wish without placing blame, and choice C explains a reaction to a specific behavior without being forceful. Therefore, D stands out as the only example of aggressive communication in the given options.
A nurse is assessing a client diagnosed with schizophrenia. Which of the following behaviors should the nurse document to be associated with schizophrenia?
- A. Recurrent thoughts of past trauma
- B. Invents words that have no meaning
- C. Preoccupied with folding clothes
- D. Periods of elation with unusual talkativeness
Correct Answer: B
Rationale: The correct answer is B: Invents words that have no meaning. This behavior is associated with a symptom of schizophrenia called "neologisms," where individuals create new words that are not part of any known language. This is a characteristic feature of disorganized thinking in schizophrenia. Recurrent thoughts of past trauma (choice A) are more aligned with symptoms of PTSD rather than schizophrenia. Being preoccupied with folding clothes (choice C) is more indicative of obsessive-compulsive disorder. Periods of elation with unusual talkativeness (choice D) are more likely symptoms of bipolar disorder rather than schizophrenia.
A nurse in a substance abuse clinic is assessing a client who is prescribed disulfiram (Antabuse). The client states he stopped the medication after developing severe nausea and vomiting. Which of the following does the nurse realize is most likely the cause of the client's symptoms?
- A. The client took an overdose of the medication.
- B. The client demonstrated an allergic response to the medication.
- C. The client experienced a common side effect of the medication.
- D. The client consumed alcohol while taking the medication.
Correct Answer: D
Rationale: The correct answer is D: The client consumed alcohol while taking the medication. Disulfiram is used to deter alcohol consumption by causing unpleasant reactions when alcohol is ingested. The symptoms of severe nausea and vomiting the client experienced are consistent with the disulfiram-alcohol reaction. This reaction occurs when alcohol is consumed while on disulfiram, leading to a buildup of acetaldehyde, causing discomfort.
Choice A: The client taking an overdose of the medication would typically result in different symptoms, such as neurological effects or liver toxicity.
Choice B: An allergic response to disulfiram would likely manifest as skin rash, itching, or difficulty breathing, rather than nausea and vomiting.
Choice C: While nausea and vomiting are common side effects of disulfiram, they are typically milder and occur when alcohol is consumed, not as a standalone symptom.
A nurse is condu,a client diagnosed with schizophrenia jumps up and runs out while yelling You are all making fun of me. The nurse recognizes that the client is displaying which of the following behaviors?cting a group therapy meeting and shares a humorous story. When the group laughs at the story
- A. Flight of ideas
- B. Erotomania
- C. Grandeur
- D. Ideas of reference
Correct Answer: D
Rationale: The correct answer is D: Ideas of reference. This behavior is exhibited when a person believes that neutral events or actions are directed at them personally. In this scenario, the client with schizophrenia perceives others are making fun of them when that may not be the case. This demonstrates a misinterpretation of external stimuli. Flight of ideas (A) refers to rapidly shifting from one idea to another. Erotomania (B) is a delusion where someone believes another person is in love with them. Grandeur (C) involves exaggerated beliefs of one's importance or power.
A nurse is discussing stress management techniques with a group of clients. Which of the following techniques mentioned by a client should the nurse recognize as the least effective?
- A. I exercise when my neck is tense.
- B. I fix myself a pot of coffee when I get anxious.
- C. I pray when I begin to breathe fast.
- D. I journal when I find it difficult to talk.
Correct Answer: B
Rationale: The correct answer is B. Fixing oneself a pot of coffee when feeling anxious is the least effective stress management technique mentioned. Caffeine in coffee can exacerbate anxiety symptoms due to its stimulant properties, leading to increased heart rate and jitteriness. Exercise (A) helps release tension, prayer (C) promotes relaxation, and journaling (D) aids in expressing emotions. Choosing coffee over these more beneficial techniques can be counterproductive in managing stress.