Nokea
A nurse is caring for a client who requires a crisis intervention for acute anxiety. Which of the following nursing actions is the highest priority?
- A. Determining the cause of the client's anxiety
- B. Identifying the client's coping skills
- C. Protecting the client from injury to himself
- D. Ensuring that the client feels safe
Correct Answer: C
Rationale: The correct answer is C: Protecting the client from injury to himself. This is the highest priority because during a crisis intervention for acute anxiety, the client may be at risk of harming themselves. Ensuring their safety is crucial before addressing other needs. Option A is important but not the highest priority in this acute situation. Option B is relevant but not as urgent as ensuring safety. Option D is also important, but physical safety takes precedence over emotional safety.
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Which of the following is a risk factor for shaken baby syndrome?
- A. Low socioeconomic status
- B. Inadequate parental education
- C. Having multiple siblings
- D. Physical disability of the caregiver
Correct Answer: A
Rationale: The correct answer is A: Low socioeconomic status. Low socioeconomic status can lead to increased stress levels and lack of access to resources, increasing the likelihood of caregiver frustration and potential for shaken baby syndrome. Inadequate parental education (B) may contribute, but is not as directly linked. Having multiple siblings (C) and physical disability of the caregiver (D) are not direct risk factors for shaken baby syndrome.
A nurse is educating a 28-year-old female client about the impacts of hypothyroidism on overall health. Which of the following statements would the nurse include in the teaching?
- A. If you become pregnant, low thyroid hormone levels can affect your developing fetus.
- B. Hypothyroidism can cause autoimmune disorders over time.
- C. Low thyroid hormone levels will cause your metabolism to speed up and heart rate to increase.
- D. Low blood pressure is usually associated with hypothyroidism.
Correct Answer: A
Rationale: Rationale: The correct answer is A because hypothyroidism, characterized by low thyroid hormone levels, can lead to complications during pregnancy, affecting fetal development. This is due to the essential role of thyroid hormones in fetal brain and nervous system development.
Summary of Incorrect Choices:
B: Hypothyroidism is linked to autoimmune disorders, not a consequence of it.
C: Hypothyroidism actually slows down metabolism and heart rate due to decreased thyroid hormone levels.
D: Low blood pressure is more commonly associated with hyperthyroidism, where the thyroid is overactive.
A male client is admitted to the unit with a possible diagnosis of delirium. Which statement by the client's wife best supports the diagnosis?
- A. Since his mother died, he has not been feeling well.
- B. My husband just didn't seem to know what he was doing. He has been forgetful for years.
- C. The changes in his behavior came on so quickly! I wasn't sure what was happening.
- D. This is supposed to happen when you get old, right?
Correct Answer: C
Rationale: The correct answer is C because delirium is characterized by a rapid onset of confusion, changes in behavior, and altered mental status. The wife's statement about the changes in behavior coming on quickly aligns with this key characteristic of delirium.
Choice A is incorrect because the client's feelings after his mother's death are not necessarily related to delirium. Choice B is incorrect because long-term forgetfulness is more indicative of dementia rather than delirium. Choice D is incorrect because delirium is not a normal part of aging.
A nurse is teaching a female client who has an anxiety disorder and is prescribed alprazolam (Xanax). Which of the following information should the nurse include in the teaching?
- A. If a dose is missed, do not double the next dose of medication.
- B. This medication may cause dizziness upon standing.
- C. Use a dependable form of contraception while taking this medication.
- D. Do not drink alcohol while taking this medication.
Correct Answer: B
Rationale: The correct answer is B: This medication may cause dizziness upon standing. Alprazolam is a benzodiazepine that can cause dizziness as a side effect, especially when standing up quickly. This information is important for the client to prevent falls or accidents.
A: Missing a dose should not be addressed by doubling the next dose as it can lead to overdose or adverse effects.
C: Although contraceptives might be important to discuss, it is not specifically related to the medication itself.
D: Alcohol should be avoided while taking alprazolam due to the increased risk of side effects and potential interactions, but it is not the most crucial information for the client's safety.
A nurse is assessing a client diagnosed with schizophrenia who has been treated with fluphenazine (Prolixin) for several years. Which of the following findings should the nurse document as manifestations of tardive dyskinesia (TD)?
- A. Sudden onset of high fever
- B. Twisting tongue movements
- C. Constant tapping of feet when sitting
- D. Shuffling gait
Correct Answer: B
Rationale: Twisting tongue movements are a classic sign of tardive dyskinesia from long-term antipsychotic use.