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A nurse is providing teaching to a client who has hypothyroidism and has been prescribed levothyroxine. Which of the following medication instructions would the nurse include in the teaching?
- A. Take this medication before a meal or several hours after a meal.
- B. Take this medication during your morning meal.
- C. Take this medication with a full glass of water or fruit juice.
- D. Take this medication with high-protein foods.
Correct Answer: A
Rationale: The correct answer is A. Levothyroxine is best absorbed on an empty stomach, so taking it before a meal or several hours after a meal ensures optimal absorption. Taking it with food or certain beverages can interfere with absorption. Choice B is incorrect as taking it during a meal may reduce absorption. Choice C is incorrect as water or fruit juice is recommended, not required in full glass quantity. Choice D is incorrect as high-protein foods can also interfere with absorption.
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A nurse is creating a plan of care for a client who is experiencing mania. Which of the following interventions should the nurse include in the plan? (Select all that apply.)
- A. Weigh the client every 3 to 4 days.
- B. Discourage the client from taking a nap during the day.
- C. Monitor vital signs throughout the day.
- D. Offer nutritional foods to the client every 2 hours.
- E. Maintain an environment with low stimuli.
Correct Answer: B,C,D,E
Rationale: The correct interventions are B, C, D, and E. B: Discouraging naps helps regulate sleep patterns in mania. C: Monitoring vital signs is crucial due to potential physical risks. D: Offering frequent, nutritional foods helps stabilize energy levels. E: Low-stimuli environment reduces agitation. A is incorrect as frequent weighing may not be necessary. F and G are not provided but would be incorrect if they do not align with managing mania symptoms.
A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?
- A. A child whose parents answer questions for the child
- B. A child who has frequent visitors
- C. A child who has a BMI indicating obesity
- D. A child who uses the call light frequently
Correct Answer: A
Rationale: The correct answer is A. When parents answer questions for the child, it may indicate a lack of autonomy or control over their own care, suggesting potential abuse or neglect. This behavior can be a red flag for the nurse to further assess the child's situation. Choices B, C, and D do not necessarily indicate abuse. Frequent visitors could be a sign of social support, obesity may be due to various factors, and using the call light frequently may indicate medical needs rather than abuse. It is essential for the nurse to explore further if a child's autonomy is being compromised.
A nurse is assessing a client who is withdrawing from alcohol. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Tremors
- B. Hyperglycemia
- C. Insomnia
- D. Visual hallucinations
- E. Severe hypotension
Correct Answer: A,C,D
Rationale: Tremors insomnia and hallucinations are typical alcohol withdrawal symptoms.
A nurse is condu,a client diagnosed with schizophrenia jumps up and runs out while yelling You are all making fun of me. The nurse recognizes that the client is displaying which of the following behaviors?cting a group therapy meeting and shares a humorous story. When the group laughs at the story
- A. Flight of ideas
- B. Erotomania
- C. Grandeur
- D. Ideas of reference
Correct Answer: D
Rationale: The correct answer is D: Ideas of reference. This behavior is exhibited when a person believes that neutral events or actions are directed at them personally. In this scenario, the client with schizophrenia perceives others are making fun of them when that may not be the case. This demonstrates a misinterpretation of external stimuli. Flight of ideas (A) refers to rapidly shifting from one idea to another. Erotomania (B) is a delusion where someone believes another person is in love with them. Grandeur (C) involves exaggerated beliefs of one's importance or power.
A nurse is caring for a client whose partner died five years ago. The nurse recognizes that which of the following findings would indicate the client is experiencing maladaptive grief?
- A. The client meets his daughter for dinner every week.
- B. The client joined a bowling league 2 months ago.
- C. The client exercises at a local health facility 3 days each week.
- D. The client has kept his partner's closet untouched since her death.
Correct Answer: D
Rationale: The correct answer is D because keeping the partner's closet untouched after five years indicates a lack of acceptance and inability to move forward in the grieving process, suggesting maladaptive grief. Choice A shows social support, B reflects engagement in a new activity, and C indicates a healthy coping mechanism through exercise.