Nokea
A nurse is performing an admission assessment on a client who has been diagnosed with schizophrenia. Which of the following findings should the nurse identify as a negative symptom?
- A. Bizarre behavior
- B. Waxy flexibility
- C. Somatic delusions
- D. Illogicality
Correct Answer: B
Rationale: Waxy flexibility reflects a lack of normal movement a negative symptom of schizophrenia.
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A nurse is assessing a client diagnosed with schizophrenia. Which of the following behaviors should the nurse document to be associated with schizophrenia?
- A. Recurrent thoughts of past trauma
- B. Invents words that have no meaning
- C. Preoccupied with folding clothes
- D. Periods of elation with unusual talkativeness
Correct Answer: B
Rationale: The correct answer is B: Invents words that have no meaning. This behavior is associated with a symptom of schizophrenia called "neologisms," where individuals create new words that are not part of any known language. This is a characteristic feature of disorganized thinking in schizophrenia. Recurrent thoughts of past trauma (choice A) are more aligned with symptoms of PTSD rather than schizophrenia. Being preoccupied with folding clothes (choice C) is more indicative of obsessive-compulsive disorder. Periods of elation with unusual talkativeness (choice D) are more likely symptoms of bipolar disorder rather than schizophrenia.
A nurse is caring for a client who has been diagnosed with end-stage liver cancer. The nurse recognizes that which of the following responses is an indication that the client is in the denial phase of the grief process?
- A. I can't believe the doctor graduated from medical school. He doesn't know a thing about treating cancer!
- B. Even though I am not hurting right now, I don't feel like I have the energy to get out of bed.
- C. The doctor says I only have a few months to live, but I know he is exaggerating to get me to take my medication.
- D. The doctor has been so good to me. I know he has tried everything he can. It's just my time.
Correct Answer: C
Rationale: The correct answer is C. In this response, the client is demonstrating denial by refusing to accept the doctor's prognosis of having only a few months to live. This indicates an inability to acknowledge the severity of the situation, a common characteristic of the denial phase in the grief process. The client's belief that the doctor is exaggerating shows a defense mechanism to cope with the overwhelming truth. Options A, B, and D do not exemplify denial. Option A shows anger, Option B indicates depression, and Option D reflects acceptance and resignation, which are not characteristics of denial in the grief process.
Medical History
• Diagnosed with anorexia nervosa at age 16.
• Participated in a weight restoration program 1 year ago.
Vital Signs
1200:
• Blood pressure: 99/59 mm Hg
• Temperature: 36.6°C (97.9°F)
• Heart rate: 58/min
• Respiratory rate: 20/min
• Oxygen saturation: 99% on room air
• Weight: 44.5 kg (98.1 lb)
• BMI: 18.5
• Height: 165.1 cm (65 in)
Nurses’ Notes
1200:
• 18-year-old client admitted to inpatient psychiatric unit after passing out at home. Client reports using laxatives and “making myself throw up after eating” for about 6 months.
1330:
• Reviewed client’s medical record and new diagnostic results; determined client is at risk for further health issues.
Diagnostic Results
1330:
• Basic metabolic panel:
o Glucose: 72 mg/dL (74 to 106 mg/dL)
o Calcium: 10.5 mg/dL (9 to 10.5 mg/dL)
o Sodium: 130 mEq/L (136 to 145 mEq/L)
o Potassium: 3.5 mEq/L (3.5 to 5 mEq/L)
o Magnesium: 2.2 mEq/L (1.3 to 2.1 mEq/L)
o Chloride: 100 mEq/L (98 to 106 mEq/L)
o BUN: 31 mg/dL (10 to 20 mg/dL)
o Creatinine: 3.0 mg/dL (0.5 to 1.0 mg/dL)
• Additional labs:
o Thyroxine, free (T4): 0.4 ng/dL (0.8 to 2.8 ng/dL)
A nurse is reviewing the medical record of a client. Exhibits Drag words from the choices below to fill in each blank in the following sentence.
The client is at risk for developing ----------------- and --------------------
.
- A. Heart Failure
- B. Renal Failure
- C. Hypomagnesemia
- D. Hypothyroidism
Correct Answer: B,D
Rationale:
The correct answer is B and D. Renal failure and hypothyroidism are conditions that can put a client at risk for developing various health issues. Renal failure can lead to electrolyte imbalances and fluid overload, increasing the risk of heart failure. Hypothyroidism can affect metabolism and cardiovascular function, also contributing to the risk of heart failure. Hypomagnesemia (choice C) is a condition characterized by low levels of magnesium in the blood and can lead to symptoms like muscle weakness and cardiac arrhythmias; however, it is not directly mentioned as a risk factor in the sentence provided. Heart failure (choice A) is a consequence or potential outcome of the conditions mentioned but is not specifically stated as a risk the client is currently facing in the sentence.
Administer heparin 1000 units per hour IV. The pharmacy supplies the heparin infusion as 25.000 units in 500 mL DSW. What will the IV pump be set to? (Include unit of measure with answer).
Correct Answer: 20
Rationale: To calculate the IV pump rate, first determine the number of units needed per mL: 25,000 units / 500 mL = 50 units per mL. Then, divide the prescribed rate of 1000 units per hour by the units per mL to get the pump setting: 1000 units / 50 units per mL = 20 mL per hour. Therefore, the correct answer is 20 mL/hour.
Incorrect choices:
A: Incorrect, doesn't follow the correct calculation method.
B: Incorrect, doesn't consider the units per mL.
C: Incorrect, doesn't involve the prescribed rate.
D: Incorrect, doesn't calculate the infusion rate.
E: Incorrect, lacks the necessary calculation steps.
F: Incorrect, doesn't relate to the given information.
G: Incorrect, doesn't follow the correct calculation process.
A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of the flu. During the night shift,the client is found climbing into the bed of another client who becomes upset and scared. Which of the following actions should the nurse take?
- A. Medicate the patient with antipsychotics.
- B. Assist the client to the correct room.
- C. Move the client to a room at the end of the hall.
- D. Place the client in restraints.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to the correct room. This is the appropriate action as it addresses the immediate issue of the client being in the wrong room, which is causing distress to the other client. Moving the client to the correct room ensures safety and comfort for both clients. Medicating with antipsychotics (choice A) is not the first-line intervention in this situation and should be avoided unless absolutely necessary due to potential side effects. Moving the client to a room at the end of the hall (choice C) may not address the underlying issue and can isolate the client unnecessarily. Placing the client in restraints (choice D) should be avoided as it can be traumatic and is not indicated in this scenario.