Nokea
After 3 weeks of treatment, a severely depressed client suddenly begins to feel better and starts interacting appropriately with other clients and staff. The nurse knows that this client has an increased risk for:
- A. Suicide
- B. Exacerbation of depressive symptoms
- C. Violence toward others
- D. Psychotic behavior
Correct Answer: A
Rationale: When the severely depressed client suddenly begins to feel better, it often indicates that the client has made the decision to kill himself or herself and has developed a plan to do so. Improvement in behavior is not indicative of an exacerbation of depressive symptoms. The depressed client has a tendency for self-violence, not violence toward others. Depressive behavior is not always accompanied by psychotic behavior.
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The charge nurse is assigning staff for the day. Staff consists of an RN, an LPN, and a certified nursing assistant. Which client assignment should be given to the nursing assistant?
- A. Exploratory laparotomy with a colon resection the previous shift
- B. Client with a stroke who has been hospitalized for two days
- C. A client with metastatic cancer on PCA morphine
- D. A new admission with diverticulitis
Correct Answer: B
Rationale: A stable stroke client (hospitalized for two days) is appropriate for a nursing assistant, who can assist with basic care (e.g., hygiene, mobility). Recent surgery (A), PCA morphine (C), and new admissions (D) require higher-level nursing skills.
The nurse is preparing to administer oral potassium chloride to an elderly client. Which action should the nurse take before administering the medication?
- A. Perform a fingerstick for morning glucose
- B. Assess for signs of hypocalcemia
- C. Withhold food for thirty minutes
- D. Check the creatinine level
Correct Answer: D
Rationale: Potassium chloride can worsen renal function in elderly clients. Checking the creatinine level assesses kidney function to ensure safe administration. Glucose hypocalcemia and withholding food are not directly related to potassium administration.
A client is admitted with a diagnosis of pernicious anemia. Which of the following signs or symptoms would indicate that the client has been noncompliant with ordered B12 injections?
- A. Hyperactivity in the evening hours
- B. Weight gain
- C. Paresthesia of hands and feet
- D. Diarrhea stools
Correct Answer: C
Rationale: Paresthesia of hands and feet indicates B12 deficiency due to noncompliance with injections, as B12 is needed for nerve function. Hyperactivity (A), weight gain (B), and diarrhea (D) are not specific to B12 deficiency.
Which finding in the patient's history contraindicates the use of Imitrex (sumatriptan) for the prevention of migraine headaches?
- A. Diabetes
- B. Angina
- C. Renal calculi
- D. Peptic ulcer disease
Correct Answer: B
Rationale: Sumatriptan (Imitrex) is a vasoconstrictor contraindicated in patients with angina due to the risk of coronary artery vasoconstriction and ischemia. Diabetes renal calculi and peptic ulcer disease are not contraindications for sumatriptan.
The nurse is caring for a client with a history of a pneumothorax who is being prepared for discharge. The nurse should teach the client to:
- A. Avoid air travel
- B. Sleep on the affected side
- C. Resume heavy lifting
- D. Restrict fluid intake
Correct Answer: A
Rationale: Air travel can cause pressure changes that risk pneumothorax recurrence. Sleeping position, lifting, and fluids are secondary, with lifting typically restricted.