Nokea
A nurse is reinforcing teaching with a newly licensed nurse about the Patient Self-Determination Act (PSDA). Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
- A. The PSDA becomes applicable when a client reaches 65 years of age.
- B. A client can verbally designate a durable power of attorney.
- C. Advance directives do not apply to clients receiving mental health care.
- D. A witness is legally required to sign a client's living will.
Correct Answer: D
Rationale: A witness is legally required to sign a client’s living will to validate the document, ensuring it’s the client’s voluntary decision. This reflects an accurate understanding of PSDA requirements.
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A nurse is collecting data from a client who has schizophrenia. Which of the following client statements indicates that the client is experiencing a command hallucination?
- A. Can you see these spiders crawling all over me?
- B. The aliens are going to abduct me tonight.
- C. Are you planning to kill me?
- D. The voices told me to quit eating the food here.
Correct Answer: D
Rationale: The statement 'The voices told me to quit eating the food here' is indicative of a command hallucination, where the client hears voices instructing them to take specific actions. This distinguishes it from visual hallucinations or delusions.
A nurse is providing information to a client about smoking cessation. Which of the following medications should the nurse include?
- A. Bupropion.
- B. Risperidone.
- C. Aripiprazole.
- D. Quetiapine.
Correct Answer: A
Rationale: Bupropion is an antidepressant also used to aid smoking cessation by reducing cravings and withdrawal symptoms. It’s specifically indicated for this purpose.
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 participating in a community program about eating disorders. Which of the following information about bulimia nervosa should the nurse include in the presentation?
- A. People who have bulimia nervosa are at risk for developing diabetes mellitus.
- B. Bulimia nervosa is difficult to notice because a person might be of average or ideal body weight.
- C. People who have bulimia nervosa eat an average amount of food on a daily basis.
- D. As long as a person is not vomiting after eating, they do not have bulimia nervosa.
Correct Answer: B
Rationale: Individuals with bulimia nervosa often maintain an average or ideal body weight, making the disorder less visible. This highlights a key characteristic for community education.
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.