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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.
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A nurse in a mental health facility is assessing a client who has schizophrenia. The nurse should document which of the following as a positive symptom?
- A. Social withdrawal
- B. Flat affect
- C. Delusions
- D. Lack of motivation
Correct Answer: C
Rationale: The correct answer is C: Delusions. Positive symptoms are behaviors or experiences that are added to a person's personality, such as hallucinations or delusions. Delusions are false beliefs that are not based on reality. In the context of schizophrenia, delusions are considered positive symptoms because they represent an addition to a person's usual behavior or mental state. Social withdrawal (A), flat affect (B), and lack of motivation (D) are considered negative symptoms of schizophrenia, as they involve a decrease or absence of normal behaviors or emotions. Therefore, the nurse should document delusions as a positive symptom in the assessment of the client with schizophrenia.
A nurse is providing teaching for a school-age child and his parents regarding a new prescription for risperidone. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will provide a low sodium diet for my son
- B. I will make sure my son takes the last dose of the day by 4 PM
- C. I should expect my son to develop hand tremors
- D. I should contact my doctor if my son urinates excessively
Correct Answer: B
Rationale: Correct Answer: B
Rationale:
1. Risperidone is known to cause sedation, so giving the last dose early can help minimize sleep disturbance.
2. Taking the last dose by 4 PM reduces the risk of insomnia or disrupted sleep patterns.
3. This statement shows the parent understands the importance of timing to optimize the medication's effects.
4. The other choices are incorrect because they do not directly relate to the appropriate use of risperidone.
A nurse is assessing a client who is experiencing alcohol withdrawal. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Visual hallucinations
- C. Hypotension
- D. Hyperactivity
Correct Answer: B
Rationale: The correct answer is B: Visual hallucinations. During alcohol withdrawal, the client may experience hallucinations due to the central nervous system's hyperexcitability. This symptom is typically seen within 12-24 hours of the last drink. Bradycardia (A) and hypotension (C) are less common in alcohol withdrawal; tachycardia and hypertension are more typical. Hyperactivity (D) is not a common symptom and is more likely to be seen in stimulant withdrawal.
A nursing is advising an assistive personnel (AP) on the care of a client who has major depressive disorder. The AP states that he is irritated by the client’s depression. Which of the following statements by the nurse is appropriate?
- A. Please don’t take what the client said seriously when she is depressed
- B. It’s important that the client feel safe verbalizing how she is feeling
- C. Everybody feels that way about this client so don’t worry about it
- D. I’ll change your assignment to someone who doesn’t have depressive disorder
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Changing the AP's assignment is appropriate because it addresses the issue of the AP's irritation towards the client's depression. It ensures the client's care is not compromised and maintains a supportive environment. This action also prevents negative attitudes from affecting the client's well-being.
Summary of other choices:
A: Incorrect. Minimizing the client's feelings is inappropriate and may invalidate their experiences.
B: Incorrect. While it is important for the client to verbalize feelings, the focus here is on addressing the AP's behavior.
C: Incorrect. Dismissing the AP's feelings and normalizing negative attitudes are not appropriate responses.
E, F, G: Not provided, but based on the context, they are likely to be irrelevant or inappropriate responses.
A nurse is planning care for a client with acute delirium. Which of the following instructions should the nurse include in the plan?
- A. Reinforce the clients orientation with the calendar
- B. Refute the clients perception of visual hallucinations
- C. Teach the client assertive techniques
- D. Assign the client to a different caregiver each shift
Correct Answer: A
Rationale: The correct answer is A: Reinforce the client's orientation with the calendar. This is because in acute delirium, the client may experience confusion and disorientation. Using a calendar can help provide structure and aid in orientation. Choice B is incorrect as refuting hallucinations may worsen the client's agitation. Choice C is incorrect as assertive techniques are not typically used in managing acute delirium. Choice D is incorrect as consistency in caregivers is important for continuity of care in delirium management.