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A nurse is working in an acute care mental health facility and is assessing a client who has schizophrenia. Which of the following findings should the nurse expect?
- A. All-or-nothing thinking.
- B. Euphoric mood.
- C. Disorganized speech.
- D. Hypochondriasis.
Correct Answer: C
Rationale: The correct answer is C: Disorganized speech. Disorganized speech is a hallmark symptom of schizophrenia, characterized by impaired thought processes that lead to incoherent, disjointed communication. All-or-nothing thinking (Choice A) is more commonly associated with cognitive distortions seen in conditions like anxiety disorders. Euphoric mood (Choice B) is not a typical finding in schizophrenia, as individuals with this disorder often display a flat or blunted affect. Hypochondriasis (Choice D) involves a preoccupation with having a serious illness and is not a primary symptom of schizophrenia.
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When providing discharge teaching to a client with diabetes, what is the most important instruction?
- A. Check blood sugar levels once daily
- B. Administer insulin as prescribed before meals
- C. Take medication only when feeling unwell
- D. Eat carbohydrate-rich meals to stabilize blood sugar
Correct Answer: B
Rationale: Administering insulin as prescribed before meals is crucial for managing diabetes. This instruction is vital as it helps the client maintain blood sugar levels within the target range. Checking blood sugar levels once daily is important but not as critical as ensuring the timely administration of insulin. Taking medication only when feeling unwell is dangerous as it may lead to uncontrolled blood sugar levels. Eating carbohydrate-rich meals may actually destabilize blood sugar levels rather than stabilizing them, making it an incorrect choice.
A nurse manager is discussing the responsibility of nurses caring for clients who have Clostridium difficile. Which of the following information should the nurse include in the teaching?
- A. Assign the client to a room with a negative air-flow system
- B. Use alcohol-based hand sanitizer when leaving the client's room
- C. Clean contaminated surfaces in the client's room with a phenol solution
- D. Have family members wear a gown and gloves when visiting
Correct Answer: D
Rationale: The correct answer is D because having family members wear a gown and gloves when visiting a client with Clostridium difficile is essential to prevent the spread of infection. Options A, B, and C are incorrect. Negative air-flow systems are not necessary for preventing the spread of C. difficile. While alcohol-based hand sanitizers are effective for routine hand hygiene, they may not be sufficient for C. difficile. Cleaning contaminated surfaces with a phenol solution is not the most effective method for preventing the spread of C. difficile, as spores can be resistant to many disinfectants.
A nurse is educating a client on how to use a cane due to left-leg weakness. What should the nurse include in the teaching?
- A. Use the cane on the stronger side
- B. Advance the cane and the weaker leg at the same time
- C. Use the cane on the weaker side
- D. Advance the cane 30 to 45 cm (12-18 in) with each step
Correct Answer: A
Rationale: The correct answer is to use the cane on the stronger side. By doing so, the client will have better support and balance. Choice B is incorrect because advancing the cane and the weaker leg at the same time may lead to instability and falls. Choice C is incorrect as using the cane on the weaker side does not provide optimal support. Choice D is incorrect as advancing the cane 30 to 45 cm (12-18 in) with each step is not a standard recommendation for cane use.
A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take to prevent infection?
- A. Monitor the client's electrolyte levels
- B. Change the TPN tubing every 24 hours
- C. Monitor blood glucose levels every 4 hours
- D. Administer insulin as prescribed
Correct Answer: B
Rationale: The correct answer is B. Changing the TPN tubing every 24 hours is crucial in preventing infection by reducing the risk of bacterial contamination. Monitoring electrolyte levels (choice A) is essential but not directly related to preventing TPN-related infections. Monitoring blood glucose levels (choice C) is important for clients receiving TPN, but it is more related to glycemic control than infection prevention. Administering insulin as prescribed (choice D) is necessary for clients with diabetes but is not directly linked to preventing TPN-related infections.
A client who is at 38 weeks of gestation and has a history of hepatitis C asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate?
- A. You may breastfeed unless your nipples are cracked or bleeding.
- B. You must use a breast pump to provide breast milk.
- C. You must use a nipple shield when breastfeeding.
- D. You may breastfeed after your baby develops antibodies.
Correct Answer: A
Rationale: The correct response is A: 'You may breastfeed unless your nipples are cracked or bleeding.' In the case of hepatitis C, breastfeeding is generally safe unless the mother's nipples are cracked or bleeding, which could increase the risk of transmission to the baby. Choice B is incorrect as using a breast pump is not a mandatory requirement for breastfeeding with hepatitis C. Choice C is incorrect as a nipple shield is not necessary in this situation. Choice D is incorrect because the baby developing antibodies does not impact the decision to breastfeed in the context of hepatitis C.