Nokea
A nurse is caring for a young female adult client who reports weakness, fatigue, and heavy menstrual periods. The client has a hemoglobin level of 8 g/dL and a hematocrit level of 28 g/dL. The nurse suspects which of the following types of anemia?
- A. Pernicious anemia
- B. Folic acid deficiency anemia
- C. Iron deficiency anemia
- D. Sickle cell anemia
Correct Answer: C
Rationale: The correct answer is C: Iron deficiency anemia. The client's low hemoglobin and hematocrit levels indicate a decrease in red blood cells, which is characteristic of anemia. Iron deficiency anemia is the most common type of anemia, typically caused by inadequate iron intake or absorption, leading to decreased production of hemoglobin. This results in symptoms like weakness, fatigue, and heavy menstrual periods, as seen in the client. Pernicious anemia (A) is due to vitamin B12 deficiency, not iron. Folic acid deficiency anemia (B) presents with similar symptoms but typically has normal iron levels. Sickle cell anemia (D) is a genetic disorder causing abnormal hemoglobin production, not related to iron deficiency.
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Which of the following factors increases a client's risk of experiencing a crisis?
- A. Stable employment
- B. Positive coping skills
- C. History of trauma
- D. Strong social support system
Correct Answer: C
Rationale: The correct answer is C: History of trauma. A history of trauma increases a client's risk of experiencing a crisis due to unresolved emotional wounds, triggering distressing memories, and impacting their ability to cope effectively. Trauma can lead to heightened stress responses and exacerbate mental health issues, making individuals more vulnerable to crises.
Incorrect choices: A) Stable employment and D) Strong social support system are protective factors that reduce the risk of crises. B) Positive coping skills enhance resilience and help individuals manage stress effectively, decreasing crisis likelihood.
A nurse is reviewing the history and physical of an adolescent client diagnosed with conduct disorder. The nurse recognizes that which of the following is an expected assessment finding of conduct disorder?
- A. Death of client's father two months ago
- B. Experiences frequent facial tics
- C. Adheres strictly to routines
- D. Suspended from school several times in the past year
Correct Answer: D
Rationale: The correct answer is D: Suspended from school several times in the past year. Conduct disorder is characterized by persistent patterns of behavior that violate the rights of others and societal norms. Being suspended from school multiple times indicates a disregard for rules and authority, which is a common feature of conduct disorder. Choices A, B, and C do not directly align with the typical behaviors associated with conduct disorder. A recent death in the family (A) may lead to emotional distress but is not a defining characteristic of conduct disorder. Frequent facial tics (B) are more indicative of a neurological or psychological condition, not conduct disorder. Adhering strictly to routines (C) is more characteristic of obsessive-compulsive disorder, not conduct disorder.
The nurse is caring for a client diagnosed with severe intellectual disability. Which of the following characteristics should the nurse recognize to be associated with severe intellectual disability?
- A. The client can perform some self-care activities independently.
- B. The client has advanced speech development.
- C. Other than possible coordination problems,the client's psychomotor skills are not affected.
- D. The client communicates wants and needs by "acting out" behaviors.
Correct Answer: D
Rationale: The correct answer is D because individuals with severe intellectual disability often have limited communication skills and may resort to "acting out" behaviors to express their wants and needs. This is a characteristic commonly associated with severe intellectual disability.
A: The client can perform some self-care activities independently - This is unlikely in severe intellectual disability as individuals typically have limitations in self-care abilities.
B: The client has advanced speech development - Individuals with severe intellectual disability often have significant delays in speech development.
C: Other than possible coordination problems, the client's psychomotor skills are not affected - Individuals with severe intellectual disability commonly have deficits in both cognitive and motor skills.
E, F, G: No additional choices provided for analysis.
A nurse on a mental health unit is caring for a client who has generalized anxiety disorder. The client received a telephone call that was upsetting,and now the client is pacing up and down the hallways of the unit. Which of the following actions should the nurse take?
- A. Instruct the client to sit down and stop pacing.
- B. Allow the client to pace alone until physically tired.
- C. Have a staff member escort the client to her room.
- D. Walk with the client at a gradually slower pace.
Correct Answer: D
Rationale: Walking with the client calmly reduces anxiety while providing support.
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.