Nokea
A nurse on the psychiatric unit is assessing a client who has moderate anxiety disorder. Which of the following findings should the nurse expect?
- A. Distorted perceptual field.
- B. Urinary frequency.
- C. Rapid speech.
Correct Answer: C
Rationale: The correct answer is C: Rapid speech. In clients with moderate anxiety, rapid speech is a common finding due to the increased arousal and nervousness associated with anxiety. The individual may talk quickly as a way to cope with their anxiety. Distorted perceptual field (A) is more indicative of severe anxiety or psychosis. Urinary frequency (B) is not a typical finding in moderate anxiety, unless there are underlying medical issues. Rapid speech (C) aligns with the increased arousal and restlessness seen in moderate anxiety.
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A nurse is assessing a client who has meningitis. Which of the following findings should the nurse expect?
- A. Blurred vision
- B. Severe headache
- C. Oriented to person, place, and year
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Severe headache. Meningitis commonly presents with severe headache due to inflammation of the meninges. This is a classic symptom and should be expected during assessment. Blurred vision (A) is not a typical finding in meningitis. Being oriented to person, place, and year (C) is a sign of intact mental status, which may not be present in someone with meningitis. Bradycardia (D) is not a common finding in meningitis; tachycardia is more likely due to the body's response to infection.
A nurse is preparing to administer clindamycin palmitate 225 mg PO every 8 hours to a client. The amount available is clindamycin palmitate oral suspension 75 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 15
Rationale: Correct Answer: 15 mL
Rationale: To calculate the mL to administer, first determine the total daily dose (675 mg). Divide this by the concentration of the oral suspension (75 mg/5 mL) to get the total mL per day (45 mL). Divide this by the number of doses per day (3) to get the mL per dose (15 mL).
Summary:
A: Incorrect, as it does not align with the correct calculation.
B-G: Irrelevant since the correct calculation method indicates 15 mL is the appropriate answer.
A nurse is caring for a client who is receiving heat applications using an aquathermia pad. Which of the following actions should the nurse take when applying the pad?
- A. Leave the pad in place for at least 40 minutes
- B. Set the pad’s temperature to 42.2°C (108°F)
- C. Use safety pins to keep the pad in place
- D. Stop the treatment if the client’s skin becomes red
Correct Answer: D
Rationale: The correct answer is D: Stop the treatment if the client’s skin becomes red. This is important because redness indicates potential skin damage or burns due to excessive heat exposure. It is crucial to monitor the client's skin during heat application to prevent harm. Choice A is incorrect because leaving the pad in place for a specific duration can lead to skin damage if the temperature is too high. Choice B is incorrect as setting the pad's temperature too high can cause burns. Choice C is incorrect as safety pins can cause injury or discomfort to the client. Therefore, the correct action is to closely monitor the client's skin for any signs of redness and stop the treatment immediately if redness occurs to prevent further harm.
A nurse is providing discharge teaching to the parent of a child who is prescribed diphenhydramine 25 mg elixir every 4 hours as needed. The amount available is diphenhydramine elixir 12.5 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 2
Rationale: Correct Answer: 2 mL
Rationale: To calculate the mL per dose, divide the prescribed mg by the concentration in mg/mL. 25 mg ÷ 12.5 mg/mL = 2 mL. This dosage ensures the correct amount of diphenhydramine is administered.
Summary of Other Choices:
A: Incorrect, as it does not calculate the dosage correctly.
B-G: Irrelevant as they do not provide any calculations or rationale for the correct dosage.
A nurse and an experienced licensed practical nurse (LPN) are caring for a group of clients. Which of the following tasks should the nurse delegate to the LPN? (Select all that apply)
- A. Plan a plan of care for a client when postoperative from an appendectomy
- B. Provide discharge instructions to a confused client’s spouse
- C. Administer a tap-water enema to a client who is preoperative
- D. Clean vital signs from a client who is 6 hours postoperative
- E. Catheterize a client who has not voided in 8 hours
Correct Answer: C,D,E
Rationale: The correct tasks to delegate to the LPN are C, D, and E. For choice C, administering a tap-water enema to a preoperative client falls within the LPN's scope of practice as it involves a routine procedure that does not require advanced assessment or critical thinking skills. Choice D, cleaning vital signs from a client who is 6 hours postoperative, is a task that can be safely delegated to the LPN as it involves routine monitoring that does not require RN-level judgment. Choice E, catheterizing a client who has not voided in 8 hours, is a task that the LPN can perform as it is a straightforward procedure that the LPN would have been trained to do. Choices A and B involve more complex decision-making and education that are typically within the RN's scope of practice.