Nokea
A young adult male who is being seen at the employee health care clinic for an annual assessment tells the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficult indeed. Which response is best for the nurse to provide?
- A. Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed.
- B. Encourage the client to seek genetic counseling to determine his risk for mental illness.
- C. Inform the client that his mother's schizophrenia has affected his psychological development.
- D. Tell the client that mental illness has a familial predisposition so he should see a psychiatrist.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?
- A. Record urine output every hour
- B. Monitor blood pressure frequently
- C. Evaluate neurological status
- D. Maintain seizure precautions
Correct Answer: B
Rationale: Pheochromocytoma is associated with severe hypertension due to excessive catecholamine release. Monitoring blood pressure frequently is the priority intervention to assess for hypertensive crises and prevent complications like stroke, heart attack, or organ damage. While recording urine output every hour, evaluating neurological status, and maintaining seizure precautions are important aspects of care, they are not the highest priority in a client with pheochromocytoma.
The school nurse is screening students for spinal abnormalities and instructs each student to stand up and then touch their toes. Which finding indicates that a student should be referred for scoliosis evaluation?
- A. Inability to touch their toes
- B. Asymmetry of the shoulders when standing upright
- C. Audible crepitus when bending
- D. An exaggerated upper thoracic convex curvature
Correct Answer: B
Rationale: Asymmetry of the shoulders when standing upright is a common indicator of scoliosis. This finding suggests a possible spinal abnormality and should prompt further evaluation. Choices A, C, and D are not specific indicators of scoliosis. Inability to touch their toes may indicate flexibility issues or tightness in the hamstrings. Audible crepitus when bending may suggest joint degeneration or inflammation. An exaggerated upper thoracic convex curvature could indicate poor posture or other spinal abnormalities but is not directly indicative of scoliosis.
A client is admitted to the labor and delivery unit in early labor, and the nurse assesses the status of her contractions. The frequency of contractions is most accurately evaluated by counting the minutes and seconds in which manner?
- A. From the peak of one contraction to the peak of the next contraction
- B. From the beginning of one contraction to the end of that contraction
- C. From the beginning of one contraction to the beginning of the next contraction
- D. From the end of one contraction to the beginning of the next contraction
Correct Answer: C
Rationale: The frequency of contractions is measured from the beginning of one contraction to the beginning of the next contraction. This timing is crucial in determining the progress of labor. Choice A, measuring from peak to peak, is incorrect as it assesses the duration between the highest points of contractions, which is not how frequency is calculated. Choice B, measuring from the beginning to the end of one contraction, is incorrect as it does not consider the start of the next contraction. Choice D, measuring from the end of one contraction to the beginning of the next contraction, is incorrect as it misses the initial onset of the following contraction.
A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amounts of liquid stool. Which action should the nurse implement?
- A. Digitally check the client for a fecal impaction
- B. Increase fluid intake to promote bowel regularity
- C. Provide a high-fiber diet to facilitate bowel movements
- D. Administer a stool softener
Correct Answer: A
Rationale: The correct answer is A: Digitally check the client for a fecal impaction. Small, frequent liquid stools following constipation may indicate a fecal impaction. This intervention is crucial to assess and address a potential impaction promptly. Choices B, increasing fluid intake, and C, providing a high-fiber diet, may help with bowel regularity in general cases, but they don't directly address the urgent concern of a possible impaction. Choice D, administering a stool softener, is not appropriate as the first action when a fecal impaction is suspected; it could worsen the condition by causing further liquid stool output without addressing the impaction.
A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?
- A. Observe the PICC line site for inflammation.
- B. Encourage increasing fluid intake.
- C. Monitor blood pressure regularly.
- D. Assess skin turgor for dehydration.
Correct Answer: A
Rationale: The correct answer is to observe the PICC line site for inflammation. When a client with a PICC line develops a fever, it could indicate an infection related to the catheter. Assessing the PICC line site for signs of inflammation, such as redness, warmth, swelling, or drainage, is crucial in identifying a potential infection early. Choice B is incorrect because increasing fluid intake is not directly related to assessing a PICC line for infection. Choice C is not the most appropriate assessment in this situation as monitoring blood pressure may not directly help in identifying the cause of the fever. Choice D is unrelated to the assessment of a fever in a client with a PICC line.