Nokea
A psychiatric client has been stabilized and is to be discharged. The nurse will recognize client insight and behavioral change by which of the following client statements?
- A. When I get home, I will need to take my medicines and call my therapist if I have any side effects or begin to hear voices.'
- B. If I have any side effects from my medicines, I will take an extra dose of Cogentin.'
- C. When I get home, I should be able to taper myself off the Haldol because the voices are gone now.'
- D. As soon as I leave here, I'm throwing away my medicines. I never thought I needed them anyway.'
Correct Answer: A
Rationale: The client verbalizes that he is responsible for compliance and keeping the treatment team member informed of progress. This behavior puts him at the lowest risk for relapse. Noncompliance is a major cause of relapse. This statement reflects lack of responsibility for his own health maintenance. This statement reflects lack of insight into the importance of compliance. This statement reflects no insight into his illness or his responsibility in health maintenance.
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Which set of vital signs would best indicate to the nurse that a client has an increase in intracranial pressure?
- A. BP 180/70, pulse 50, respirations 16, temperature 101°F
- B. BP 100/70, pulse 64, respirations 20, temperature 98.6°F
- C. BP 96/70, pulse 132, respirations 20, temperature 98.6°F
- D. BP 130/80, pulse 50, respirations 18, temperature 99.6°F
Correct Answer: A
Rationale: Increased ICP is indicated by Cushing’s triad: hypertension (BP 180/70), bradycardia (pulse 50), and irregular respirations. Option A best matches this, with fever as a possible secondary sign. Options B, C, and D lack this combination.
The client is admitted with left-sided congestive heart failure. In assessing the client for edema, the nurse should check the:
- A. Feet
- B. Neck
- C. Hands
- D. Sacrum
Correct Answer: D
Rationale: In left-sided congestive heart failure, fluid backs up into the lungs, but dependent edema is assessed in the sacrum in bedridden clients or feet in ambulatory clients. The sacrum is the most appropriate site for hospitalized clients, as they are often recumbent.
A 24-year-old client presents to the emergency department protesting 'I am God.' The nurse identifies this as a:
- A. Delusion
- B. Illusion
- C. Hallucination
- D. Conversion
Correct Answer: A
Rationale: A delusion is a false belief, such as claiming to be God, common in psychotic disorders.
The physician has diagnosed a client with cirrhosis characterized by asterixis. If the nurse assesses the client with asterixis, he can expect to find:
- A. Irregular movement of the wrist
- B. Enlargement of the breasts
- C. Dilated veins around the umbilicus
- D. Redness of the palmar surfaces
Correct Answer: A
Rationale: Asterixis, a flapping tremor of the wrists when extended, is a sign of hepatic encephalopathy in cirrhosis due to ammonia buildup. The other findings are unrelated to asterixis.
A client with cancer is experiencing a common side effect of chemotherapy administration. Which laboratory assessment finding would cause the most concern?
- A. A sodium level of 50 mg/dL
- B. A blood glucose of 110 mg/dL
- C. A platelet count of 125,000/mm3
- D. A white cell count of 5,000/mm3
Correct Answer: A
Rationale: A sodium level of 50 mg/dL is impossible (likely a typo for 50 mEq/L, which is severely hyponatremic) and life-threatening, causing seizures. Glucose (B), platelets (C), and WBC (D) are near normal or less critical.