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A nurse is teaching a group of clients with a diagnosis of Schizophrenia who are nearing discharge from a residential care facility. An essential topic to include is:
- A. pathophysiology of the disease and expected symptoms.
- B. how to recognize and manage symptoms of relapse.
- C. the need to take extra medication when feeling stressed.
- D. the importance of contact with follow-up care daily.
Correct Answer: B
Rationale: Clients are usually aware of the symptoms that indicate relapse is occurring. The client needs to know how to find a safe environment and to seek help. The first two stages of relapse are more difficult to recognize because they do not present symptoms that indicate psychosis. Initially, the client feels anxious and overwhelmed, and might become withdrawn. This is the crucial period to intervene. The client needs to go to a safe environment with someone who is trusted, avoid negative people, and decrease stimuli and stress.
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A nurse is reviewing a patient's serum glucose levels. Which of the following scenarios would indicate abnormal serum glucose values for a 30 year-old male.
- A. 70 mg/dl
- B. 55 mg/dl
- C. 110 mg/dl
- D. 100 mg/dl
Correct Answer: B
Rationale: 60-115 mg/dl is standard range for serum glucose levels.
An adolescent female reports being raped at a party where alcohol was served. The client admits to drinking alcohol before being raped by an acquaintance. The nurse should:
- A. Inform the client that because she is underage, she is at fault for attending a party where alcohol was served
- B. Ask the client if anyone witnessed the event because the client was intoxicated and might not remember correctly
- C. Inform the client that it was not her fault, and support the client through the physical examination
- D. Question whether the woman had consensual sex and now just feels guilty
Correct Answer: C
Rationale: Supporting the client and affirming that the rape was not her fault is critical, as acquaintance rape is serious and not negated by alcohol consumption.
Which of the following blood pressure parameters indicates PIH? Elevation over a baseline of:
- A. 30 mmHg systolic and/or 15 mmHg diastolic.
- B. 40 mmHg systolic and/or 20 mmHg diastolic.
- C. 10 mmHg systolic and/or 5 mmHg diastolic.
- D. 20 mmHg systolic and/or 20 mmHg diastolic.
Correct Answer: A
Rationale: These are the accepted parameters for mild PIH. Mild preclampsia includes an increase in systolic blood pressure higher than 30 mmHg or an increase in diastolic blood pressure higher than 15 mmHg, noted on two readings taken 6 hours apart (or 140/90).
When discussing the patterns of use of alcohol and other drugs, the nurse should include which piece of information?
- A. Lifetime prevalence and intensity of alcohol use is greater in women than men
- B. Hispanics and African Americans have higher levels of alcohol use than Caucasians
- C. Overuse of alcohol and other drugs increases into the mid-20s, then levels off and decreases with age
- D. Heavy use is more common in higher socioeconomic groups because they can afford to buy the drugs
Correct Answer: C
Rationale: Alcohol and drug use peaks in the mid-20s and decreases with age. Men have higher prevalence, Caucasians report more alcohol use, and heavy use is more common among less educated or unemployed groups.
The nurse suspects an elderly client has been the victim of abuse. The client denies abuse and declines assistance. The nurse's next action should be to:
- A. do nothing; the client has the right to refuse treatment.
- B. report the incident to the police.
- C. arrange an appointment with the client's next of kin.
- D. educate the client about available services.
Correct Answer: D
Rationale: Although clients do have the right to refuse treatment, the nurse should remain nonjudgmental and inform the client of available services. Frequently elders are not aware of existing programs.