Nokea
A nurse is assessing an 82-year-old for depression, because of the client's age, the nurses' assessment should be guided by the fact that:
- A. Sadness of mood is usually present but it is masked by other symptoms.
- B. Impairment of cognition usually is not present.
- C. Psychosomatic tendencies do not tend to dominate.
- D. Antidepressant therapies are less effective in older adults.
Correct Answer: A
Rationale: In older adults, depression may present with atypical symptoms, such as somatic complaints or irritability, rather than overt sadness, which can mask the condition.
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The nurse is caring for a client with a history of epilepsy who is prescribed valproic acid (Depakene). Which of the following laboratory tests should the nurse monitor?
- A. Liver function tests.
- B. Renal function tests.
- C. Complete blood count.
- D. Blood glucose levels.
Correct Answer: A
Rationale: Valproic acid can cause hepatotoxicity, requiring regular monitoring of liver function tests.
A client is admitted to the hospital with the diagnosis of Cushing's disease. The nurse should monitor the client's laboratory studies for which associated disorder?
- A. Hypokalemia
- B. Hyperglycemia
- C. Decreased plasma cortisol levels
- D. Low white blood cell (WBC) count
Correct Answer: B
Rationale: The client with adrenocorticosteroid excess experiences hyperglycemia, hyperkalemia, elevated plasma cortisol and adrenocorticotropic hormone (ACTH) levels, and an elevated WBC count. These abnormalities are caused by the effects of excess glucocorticoids and mineralocorticoids on the body.
A client with a history of myocardial infarction is prescribed aspirin. What is the primary purpose of this medication?
- A. Reduce fever.
- B. Prevent platelet aggregation.
- C. Relieve chest pain.
- D. Lower cholesterol.
Correct Answer: B
Rationale: Aspirin prevents platelet aggregation, reducing the risk of thrombus formation in clients with a history of myocardial infarction.
A client is admitted to the hospital with a diagnosis of infiltrating ductal carcinoma of the breast. Which expected manifestation should the nurse assess the client for?
- A. Bilateral palpable masses
- B. Pain in the breast and edema
- C. A fixed, irregularly shaped mass
- D. A round-shaped mass that is moveable
Correct Answer: C
Rationale: Infiltrating ductal carcinoma of the breast usually presents as a fixed, irregularly shaped mass. The mass is usually single and unilateral and is painless, nontender, and hard to the touch.
Select the term which is most completely and accurately paired with its definition.
- A. A physical restraint: A physical restraint is a manufactured device that is used, when necessary, to prevent falls.
- B. A physical restraint: A physical restraint is any mechanical device, material, or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body.
- C. A chemical restraint: A chemical restraint is a drug used for sedation to prevent falls.
- D. A chemical restraint: A chemical restraint is a drug used for discipline or convenience and not required to treat medical symptoms.
Correct Answer: B,D
Rationale: A physical restraint is correctly defined as a device restricting movement that the client cannot easily remove. A chemical restraint is a drug used for discipline or convenience, not for medical symptoms, such as preventing falls .