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A nurse is talking with the guardian of a school-aged child recently diagnosed with intermittent explosive disorder (IED). The guardian says,My child is impulsive, acts out aggressively, and then seems pleased with themselves. How can my child be happy? Which of the following responses should the nurse make?
- A. Appearing pleased after an aggressive or impulsive act has not been directly linked to intermittent explosive disorder.
- B. Appearing pleased after an aggressive or impulsive act can be a sense of relief rather than being happy.
- C. Appearing pleased after an aggressive or impulsive act is a manifestation of lack of empathy or compassion.
- D. Appearing pleased after an aggressive or impulsive act is within the control of your child.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: The nurse should choose response B because it addresses the guardian's concern accurately. Individuals with intermittent explosive disorder may experience a sense of relief rather than genuine happiness after acting out aggressively. This relief can stem from a temporary release of pent-up emotions or stress. It is important for the nurse to clarify this distinction to the guardian to help them understand their child's behavior better and guide appropriate interventions.
Incorrect Choices:
A: This response dismisses the guardian's observations and does not provide a helpful explanation.
C: This response inaccurately suggests a lack of empathy or compassion, which is not a defining characteristic of intermittent explosive disorder.
D: This response implies that the behavior is under the child's control, which is not necessarily the case with impulsive disorders like IED.
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A nurse is caring for a postoperative client following a total knee replacement. Which of the following medications should the nurse anticipate the provider to prescribe to prevent the formulation of a deep vein thrombosis (DVT)?
- A. Enoxaparin
- B. Alteplase (tPA)
- C. Warfarin
- D. Clopidogrel
Correct Answer: A
Rationale: The correct answer is A: Enoxaparin. Enoxaparin is a low molecular weight heparin that helps prevent deep vein thrombosis (DVT) by inhibiting clot formation. It is commonly prescribed postoperatively for clients undergoing knee replacement surgery due to the increased risk of DVT. Alteplase (tPA) is a thrombolytic agent used to dissolve existing blood clots and not typically used for prevention. Warfarin is an oral anticoagulant that requires monitoring of INR levels and is usually started after initial treatment with heparin. Clopidogrel is an antiplatelet agent and is not typically used for DVT prevention.
A nurse is developing a plan of care for a client with bipolar I disorder,hospitalized for heart failure and showing signs of lithium toxicity. Which of the following interventions should the nurse include? (Select all that apply.)
- A. Set up a dietary consult for a low-sodium diet.
- B. Notify the provider of potential medication interactions.
- C. Withhold next dose of lithium.
- D. Educate the client about the need for hemodialysis.
- E. Discuss contraception.
- F. Assess need for and administer prochlorperazine PRN.
Correct Answer: B
Rationale:
A nurse is teaching a newly licensed nurse about heparin-induced thrombocytopenia. Which of the following risk factors for this disorder should the nurse include in the teaching?
- A. Systemic lupus erythematosus
- B. Placental abruption
- C. Heparin therapy for deep-vein thrombosis
- D. Warfarin therapy for atrial fibrillation
Correct Answer: C
Rationale: Rationale: Heparin-induced thrombocytopenia (HIT) is a rare but serious complication of heparin therapy, causing a drop in platelet count. The correct answer is C because heparin therapy for deep-vein thrombosis is a known risk factor for HIT. Systemic lupus erythematosus (choice A) is associated with other complications but not specifically HIT. Placental abruption (choice B) is a condition related to pregnancy complications. Warfarin therapy for atrial fibrillation (choice D) is not a risk factor for HIT. Therefore, the nurse should focus on heparin therapy as a significant risk factor in HIT education.
A nurse is caring for a client who has bipolar disorder. Which of the following actions by the client should the nurse interpret as displaying manic behavior? (Select all that apply.)
- A. Impulsive behaviors
- B. Sleeping for long periods of time
- C. Interacting with others in a flirtatious way
- D. Dressing in black or grey clothing
- E. Talking in rapid,continuous speech
Correct Answer: A,C,E
Rationale: The correct answers are A, C, and E. Impulsive behaviors, interacting flirtatiously, and talking rapidly are classic manifestations of manic behavior in bipolar disorder. Impulsive actions can lead to risky behaviors. Flirtatious interactions are often inappropriate and lack boundaries. Rapid, continuous speech is a hallmark of mania, reflecting racing thoughts and pressured speech. Choices B and D do not align with manic behavior. Sleeping for long periods is more indicative of depression, while dressing in black or grey clothing does not directly correlate with manic episodes.
A nurse is reviewing the medical records of clients on a hospital floor. Which client would the nurse expect is most at risk for hyperthyroidism?
- A. A 45-year-old female who has a family history of autoimmune disorders
- B. A 73-year-old male who has an iodine deficiency
- C. A 25-year-old female who has metabolic syndrome
- D. A 35-year-old male who has Graves' disease
Correct Answer: D
Rationale: The correct answer is D: A 35-year-old male who has Graves' disease. Graves' disease is a common cause of hyperthyroidism characterized by an overactive thyroid gland. Individuals with Graves' disease often present with symptoms such as weight loss, tremors, and palpitations. The autoimmune nature of Graves' disease leads to the production of thyroid-stimulating immunoglobulins, resulting in excess thyroid hormone production. Therefore, a client with a known diagnosis of Graves' disease is at the highest risk for hyperthyroidism.
A: A 45-year-old female with a family history of autoimmune disorders may be at risk for developing autoimmune conditions, including hyperthyroidism, but without a current diagnosis of hyperthyroidism, she is not the most at risk in this scenario.
B: A 73-year-old male with iodine deficiency is more likely to develop hypothyroidism rather than hyperthyroidism, as iodine deficiency is a common cause