Nokea
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.
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The nurse is teaching a client about cellular hypertrophy. Which statement should be included in the teaching?
- A. It's uncontrolled proliferative cell growth that is cancerous.
- B. It's the enlargement of an organ or tissue from the increase in cell size.
- C. It's the wasting away of tissue or organs.
- D. It's the abnormal growth or development of cells.
Correct Answer: B
Rationale: The correct answer is B because cellular hypertrophy refers to the increase in the size of cells leading to the enlargement of an organ or tissue. This is a normal physiological response to increased demand or stress. Choice A is incorrect as uncontrolled proliferative cell growth leading to cancer is known as neoplasia, not hypertrophy. Choice C is incorrect as wasting away of tissue is termed as atrophy, not hypertrophy. Choice D is incorrect as abnormal cell growth or development is more indicative of dysplasia or metaplasia, not hypertrophy.
A nurse in an acute mental health unit is admitting a client diagnosed with bipolar disorder. The nurse recognizes which of the following findings supports the admitting diagnosis of acute mania?
- A. The client responds to questions with disorganized speech.
- B. The client has lost interest in sexual relations.
- C. The client reports that voices are telling him to write a novel.
- D. The client's spouse reports that the client has recently gained weight.
Correct Answer: A
Rationale: The correct answer is A because responding to questions with disorganized speech is a common symptom of acute mania in bipolar disorder. This symptom is indicative of the manic phase, where individuals often exhibit pressured speech, flight of ideas, and tangential thinking. Choice B, loss of interest in sexual relations, is more associated with depression than mania. Choice C, hearing voices instructing to write a novel, is more suggestive of psychosis rather than mania. Choice D, weight gain, is not a specific symptom of acute mania.
Susan,the nurse is caring for a client who states "I plan to commit suicide." Which of the following assessments should the nurse identify as the priority?
- A. Lethality of the method and availability of means
- B. Client's educational and economic background
- C. Client's insight into the reasons for the decision
- D. Quality of the client's social support
Correct Answer: A
Rationale: The correct answer is A. Assessing the lethality of the method and availability of means is the priority because it directly addresses the client's immediate safety. Understanding how easily the client can access the means to commit suicide is crucial in preventing harm. Choices B, C, and D are important aspects of a comprehensive assessment but do not directly address the immediate risk of suicide. Choice B focuses on background information, which may be relevant for understanding the client but is not the priority in this urgent situation. Choice C pertains to the client's insight, which is important for therapeutic interventions but does not address the imminent risk. Choice D considers social support, which is valuable in long-term prevention but not the immediate concern.
A nurse in the acute mental health unit is admitting a new client with an eating disorder. The nurse is aware that which of the following are considered comorbidities of eating disorders? (Select all that apply.)
- A. Anxiety
- B. Depression
- C. Obsessive-compulsive disorder
- D. Schizophrenia
- E. Breathing-related sleep disorder
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C. Anxiety, depression, and obsessive-compulsive disorder are commonly seen as comorbidities in individuals with eating disorders. Anxiety and depression are often present due to the psychological stress and emotional turmoil associated with the eating disorder. Obsessive-compulsive disorder can manifest in obsessive thoughts about food, weight, and body image, as well as compulsive behaviors related to eating and exercise. Schizophrenia and breathing-related sleep disorder are not typically associated with eating disorders, making choices D and E incorrect. It is essential for the nurse to be aware of these comorbidities to provide holistic care to the client.
A nurse is caring for a child who has autism spectrum disorder. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Ritualistic behavior
- B. Short attention span
- C. Spinning a toy repetitively
- D. Consistent limit testing
- E. Delayed language development
Correct Answer: A,B,C,E
Rationale: The correct findings for a child with autism spectrum disorder are A, B, C, and E. A: Ritualistic behavior is common in children with ASD due to their need for predictability and routine. B: Short attention span is often seen in children with ASD, affecting their ability to focus on tasks. C: Spinning a toy repetitively is a stereotypical behavior associated with ASD, serving as a self-soothing mechanism. E: Delayed language development is a hallmark feature of ASD, impacting communication skills. These findings align with the core characteristics of ASD. Choices D and beyond are incorrect as they do not typically align with common manifestations of ASD in children.