Nokea
After several months of taking olanzapine (Zyprexa), the client reports that he is no longer hearing voices of any kind. Which of the following would confirm that the client is developing insight into his illness?
- A. That Zyprexa is the best medicine I have ever had.'
- B. I didn't realize how sick I could get from a chemical brain imbalance.'
- C. My mom is proud of me for staying on my medicines.'
- D. I think I may be able to get a little part-time job soon.'
Correct Answer: B
Rationale: Acknowledging a chemical brain imbalance shows insight into the biological basis of the illness, indicating understanding of the need for treatment.
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Which statement about targeted assessments is accurate?
- A. The need for a targeted assessment is based on the application of the nurse's knowledge of pathophysiology and the presenting symptoms.
- B. The need for a targeted assessment is based on the application of the nurse's knowledge of developmental needs and developmental delays.
- C. Targeted assessment is done on an annual basis for existing clients rather than a complete assessment that is done for new clients.
- D. Targeted assessments consist of a brief medical history and a complete assessment consists of a complete health history and a complete physical assessment.
Correct Answer: A
Rationale: Targeted assessments focus on specific health issues based on the nurse's knowledge of pathophysiology and the patient's presenting symptoms, allowing for a focused evaluation rather than a comprehensive one.
The nurse is preparing to administer a measles, mumps, and rubella (MMR) vaccine to a 15-month-old. Where should the nurse administer the injection?
- A. Deltoid muscle
- B. Vastus lateralis muscle
- C. Gluteal muscle
- D. Subcutaneous tissue of the abdomen
Correct Answer: B
Rationale: The vastus lateralis is the preferred site for intramuscular vaccines like MMR in toddlers due to adequate muscle mass and low risk of nerve damage.
Which of the following is an adverse effect to therapeutic radiation therapy?
- A. Fibrosis
- B. Alopecia
- C. Oral dryness
- D. Xerostomia
Correct Answer: D
Rationale: Xerostomia (dry mouth) is a common adverse effect of radiation therapy, particularly when the head or neck is irradiated, due to damage to salivary glands.
As the nurse in a primary care clinic, which cultural concern would you integrate into your psychological assessments of your clients?
- A. The concern related to the client's cultural reluctance to report psychological symptoms because of some possible culturally based stigma associated with psychiatric mental health disorders
- B. Concerns revolving around the lack of financial and health insurance resources to pay for psychological care
- C. Concerns related to the compliance with psychological treatment regimens because of the client's lack of social support systems
- D. The concern related to the culturally based client apathy about nursing care and nursing assessments
Correct Answer: A
Rationale: Cultural stigma around mental health can significantly impact clients' willingness to report psychological symptoms, making it a critical consideration in assessments.
Thirty minutes after a Sengstaken-Blakemore tube is inserted, the nurse observes that the client appears to be having difficulty breathing. The nurse's first action should be to:
- A. Remove the tube.
- B. Deflate the esophageal portion of the tube.
- C. Determine whether the tube is obstructing the airway.
- D. Increase the oxygen flow rate.
Correct Answer: C
Rationale: Difficulty breathing may indicate airway obstruction by the Sengstaken-Blakemore tube, so assessing this is the priority action.