Nokea
A nurse is collecting data from a client who is experiencing opioid withdrawal. Which of the following manifestations should the nurse expect?
- A. Diarrhea.
- B. Hypokinesis.
- C. Bradycardia.
- D. Meiosis.
Correct Answer: A
Rationale: Diarrhea is a common symptom of opioid withdrawal due to increased gastrointestinal motility. This reflects the body’s reaction to the absence of opioids.
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A nurse is contributing to the plan of care for a client who has bipolar disorder and whose admission was voluntary. For which of the following interventions should the nurse confirm that the client has given informed consent?
- A. Receiving light therapy.
- B. Taking an experimental medication.
- C. Participating in a group exercise program.
- D. Attending a cognitive behavioral therapy class.
Correct Answer: B
Rationale: Experimental medications require informed consent due to the potential unknown effects and risks. Ensuring the client is fully informed about the experimental nature and possible side effects is crucial, unlike routine interventions like light therapy or therapy classes.
A nurse is preparing to administer sertraline 50 mg PO once daily to a client who has depressive disorder. Available is sertraline oral solution 20 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 2.5
Rationale: Step 1: (50 mg ÷ 20 mg/mL) × 1 mL = 2.5 mL. The nurse should administer 2.5 mL to deliver the prescribed 50 mg dose, calculated based on the concentration of the available solution.
A nurse is reviewing the medical record of a client who is to receive electroconvulsive therapy. The nurse should notify the provider for which of the following findings?
- A. Asthma.
- B. Crohn's disease.
- C. Renal colic.
- D. Cardiac arrhythmia.
Correct Answer: D
Rationale: Cardiac arrhythmia is a contraindication for ECT because the procedure can increase the risk of cardiac complications. ECT involves electrical stimulation that can affect heart rhythm, requiring prior cardiac evaluation.
A nurse is assisting with teaching a group of older adult clients about behavioral expectations. Which of the following actions should the nurse take to help eliminate barriers to learning?
- A. Schedule the teaching sessions for a long time to promote participation.
- B. Use 'I' statements rather than 'you' statements.
- C. Assist the clients with establishing long-term goals.
- D. Ensure the teaching sessions occur right before bedtime.
Correct Answer: B
Rationale: Using 'I' statements rather than 'you' statements helps build rapport and reduces defensiveness. It fosters a supportive learning environment, making communication more effective for older adults.
A nurse is collecting data from a client who has bulimia nervosa. Which of the following findings should the nurse expect?
- A. Lanugo.
- B. Muscle wasting.
- C. Hypokalemia.
- D. Hypomagnesemia.
Correct Answer: C
Rationale: Hypokalemia, low potassium levels, is a common finding in bulimia nervosa due to repeated vomiting and laxative use. These behaviors lead to significant electrolyte imbalances, posing serious health risks.