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A patient keeps saying, "I feel hot. Hot, cot, rot, tot, got. I'm a spot.' This is an illustration of:

  • A. Blocking.
  • B. Clanging.
  • C. Echolalia.
  • D. Neologism.
Correct Answer: B

Rationale: The correct answer is B: Clanging. Clanging refers to the phenomenon where words are chosen based on sound rather than meaning. In this case, the patient's speech demonstrates a pattern of words that rhyme or have similar sounds, despite lacking coherence or logical connection. This behavior is commonly seen in individuals with conditions like schizophrenia.

Incorrect choices:
A: Blocking - Blocking refers to sudden interruption or cessation of speech. This does not apply to the scenario described.
C: Echolalia - Echolalia involves repetition of words or phrases spoken by others, not self-generated word patterns like in the scenario.
D: Neologism - Neologism refers to the creation of new words or phrases with unique meanings, which is not reflected in the patient's speech pattern.

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The nurse is conducting a physical assessment. The data the nurse would collect vary depending on what?

  • A. How much time the nurse has
  • B. The client's acuity
  • C. The client's cooperation
  • D. Onset of current symptoms
Correct Answer: B

Rationale: Step 1: The nurse should prioritize collecting data based on the client's acuity to address immediate needs and ensure patient safety.
Step 2: Acuity determines the urgency and intensity of care required, guiding the assessment focus.
Step 3: Time available or client cooperation may influence the depth of assessment but do not dictate the data collected.
Step 4: The onset of symptoms is important for history-taking but not the primary factor in determining assessment data.

What is the first intervention when a client develops symptoms of shock?

  • A. Administer oxygen
  • B. Administer IV fluids
  • C. Monitor respiratory rate
  • D. Administer pain medication
Correct Answer: A

Rationale: The correct answer is A: Administer oxygen. Oxygen administration is the first intervention for shock as it helps improve oxygenation to vital organs. Lack of oxygen can worsen shock. Administering IV fluids (choice B) could be the second step to improve perfusion. Monitoring respiratory rate (choice C) is important but not the first intervention. Administering pain medication (choice D) is not a priority in managing shock.

What should a nurse assess for in a client with an arteriovenous fistula for hemodialysis?

  • A. Inspect for visible pulsation
  • B. Palpate for thrill
  • C. Auscultate for bruit
  • D. Percuss for dullness
Correct Answer: A

Rationale: The correct answer is A: Inspect for visible pulsation. This is because an arteriovenous fistula for hemodialysis should have a visible pulsation, indicating proper blood flow. Palpating for thrill (B) and auscultating for bruit (C) are also common assessments for an arteriovenous fistula, but inspecting for visible pulsation is the most direct and reliable way to assess the patency of the fistula. Percussing for dullness (D) is not relevant in this context as it does not provide information about the vascular access site.

What should be done for a client who is post-op and develops a fever within the first 48 hours?

  • A. Administer antipyretics
  • B. Monitor for signs of infection
  • C. Administer fluids
  • D. Perform an abdominal assessment
Correct Answer: B

Rationale: The correct answer is B: Monitor for signs of infection. Within the first 48 hours post-op, fever is often indicative of an infection. Monitoring for signs such as increased pain, redness, swelling, warmth at the surgical site, elevated white blood cell count, and changes in vital signs helps in early detection and prompt treatment of infections. Administering antipyretics (choice A) may help reduce fever but does not address the underlying cause. Administering fluids (choice C) is important for hydration but does not directly address the fever's cause. Performing an abdominal assessment (choice D) is not specific to addressing fever in a post-op client.

A nurse is caring for a patient with chronic kidney disease (CKD). Which of the following lab results would the nurse expect to be elevated in this patient?

  • A. Blood urea nitrogen (BUN).
  • B. Calcium.
  • C. Potassium.
  • D. Sodium.
Correct Answer: A

Rationale: The correct answer is A: Blood urea nitrogen (BUN). In CKD, the kidneys are unable to effectively filter waste products, leading to an increase in BUN levels. Elevated BUN indicates impaired kidney function. Calcium, potassium, and sodium levels may also be affected in CKD, but they are more likely to be imbalanced rather than consistently elevated. Calcium levels may be low due to impaired vitamin D activation, potassium levels may be high due to decreased excretion, and sodium levels can fluctuate based on fluid status. Therefore, while these lab values may be abnormal in CKD, BUN is the most consistently elevated marker of kidney dysfunction.

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