Nokea
A nurse is assisting with obtaining informed consent from a client who has been declared legally incompetent. Which of the following actions should the nurse take?
- A. Contact the facility social worker to obtain the consent
- B. Explain implied consent to the client’s family
- C. Request that the client’s guardian sign the consent
- D. Ask the charge nurse to obtain informed consent
Correct Answer: C
Rationale: The correct answer is C: Request that the client’s guardian sign the consent. This is appropriate because a legally incompetent individual requires a guardian to make decisions on their behalf. This ensures that the client's best interests are protected and that decisions are made by someone legally authorized to do so. Choice A is incorrect because social workers are not authorized to provide consent for legally incompetent individuals. Choice B is incorrect as implied consent is not applicable in this scenario. Choice D is incorrect as the charge nurse does not have the legal authority to obtain informed consent for a legally incompetent client.
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A nurse is assessing a client who requires bupropion for smoking cessation. Which of the following findings in the client’s history should the nurse recognize as a contraindication for taking this medication?
- A. Seizures
- B. Anemia
- C. Migraines
- D. Asthma
Correct Answer: A
Rationale: The correct answer is A: Seizures. Bupropion is contraindicated in individuals with a history of seizures due to the potential to lower the seizure threshold. This can increase the risk of seizures occurring. Anemia (B), migraines (C), and asthma (D) are not contraindications for taking bupropion. Anemia and migraines are not directly related to the use of bupropion, and in some cases, bupropion may even help with migraines. Asthma, while a consideration, is not a contraindication for taking bupropion.
A nurse in an inpatient mental health facility is assessing a client who has schizophrenia and is taking haloperidol. Which of the following clinical findings is the nurse’s priority?
- A. High fever
- B. Insomnia
- C. Urinary hesitancy
- D. Headache
Correct Answer: A
Rationale: The correct answer is A: High fever. The priority finding is high fever because it could indicate a potentially serious adverse reaction called neuroleptic malignant syndrome (NMS) associated with haloperidol use. NMS is a life-threatening condition characterized by fever, altered mental status, muscle rigidity, and autonomic dysfunction. Prompt recognition and treatment of NMS are crucial to prevent complications. Insomnia (B), urinary hesitancy (C), and headache (D) are common side effects of haloperidol but are not as urgent as high fever, which could signify a medical emergency.
A nurse is caring for a client who has a new diagnosis of bulimia nervosa. Which of the following diagnosis procedures should the nurse anticipate the provider should describe during the medical evaluation?
- A. Chest x-ray
- B. ECG
- C. Coagulation studies
- D. Liver function test
Correct Answer: B
Rationale: The correct answer is B: ECG. A provider may order an ECG during the medical evaluation of a client with bulimia nervosa to assess for any potential cardiac complications, such as electrolyte imbalances or arrhythmias due to purging behaviors. This test helps in evaluating the overall cardiac health of the client. Chest x-ray (A) is not typically indicated in the evaluation of bulimia nervosa unless there are specific respiratory symptoms. Coagulation studies (C) are not directly related to the diagnosis of bulimia nervosa. Liver function test (D) is not a common diagnostic procedure for bulimia nervosa unless there are specific concerns about liver function due to other factors.
A nurse is reviewing the laboratory results of a client who is taking lithium. Which of the following values should the nurse report to the provider?
- A. Lithium level 0.6 mEq/L
- B. Sodium 135 mEq/L
- C. Creatinine 1.5 mg/dL
- D. Potassium 4.0 mEq/L
Correct Answer: C
Rationale: The correct answer is C: Creatinine 1.5 mg/dL. Elevated creatinine levels indicate potential kidney damage from lithium toxicity. The nurse should report this value to the provider for further evaluation. Choices A, B, and D are within normal ranges and not directly related to lithium toxicity. Therefore, they do not require immediate attention.
A nurse is developing a plan of care for a client who has post-traumatic stress disorder. Which of the following interventions should the nurse include?
- A. Encourage the client to suppress traumatic memories
- B. Discourage the client from discussing the trauma
- C. Encourage the client to use relaxation techniques
- D. Limit the client’s participation in activities
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to use relaxation techniques. This is important in managing symptoms of PTSD by helping the client to reduce anxiety and stress levels. Relaxation techniques, such as deep breathing and mindfulness, can help the client cope with distressing thoughts and emotions. Encouraging the client to use these techniques promotes self-soothing and emotional regulation.
Choice A is incorrect because suppressing traumatic memories can worsen symptoms and lead to increased distress. Choice B is incorrect as discussing the trauma in a safe and supportive environment is a key component of PTSD therapy. Choice D is incorrect as limiting activities can hinder the client's recovery process.