Nokea
Assessment of a client who has just been admitted to the inpatient psychiatric unit reveals an unshaven face, noticeable body odor, visible spots on the shirt and pants, slow movements, gazing at the floor, and a flat affect. Which of the following should the nurse interpret as indicating psychomotor retardation?
- A. Slow movements.
- B. Flat affect.
- C. Unkempt appearance.
- D. Avoidance of eye contact.
Correct Answer: A
Rationale: Slow movements are a hallmark of psychomotor retardation, often seen in depression or other psychiatric conditions.
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A client with a diagnosis of breast cancer is prescribed anastrozole (Arimidex). The nurse should instruct the client to report which of the following side effects immediately?
- A. Hot flashes.
- B. Bone pain.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: Bone pain may indicate bone loss or metastasis, a serious side effect of anastrozole requiring immediate reporting.
Which of the following abnormal serum chemistry results is a client with cirrhosis who has developed ascites likely to have?
- A. Decreased aspartate aminotransferase.
- B. Hypoalbuminemia.
- C. Hyperkalemia.
- D. Decreased alanine aminotransferase.
Correct Answer: B
Rationale: Cirrhosis impairs liver protein synthesis, leading to hypoalbuminemia, which causes ascites due to decreased oncotic pressure.
A client with chronic renal failure is receiving epoetin alfa (Epogen). The nurse should monitor the client for which of the following adverse effects?
- A. Hypertension.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypokalemia.
Correct Answer: A
Rationale: Epoetin alfa can cause hypertension due to increased red blood cell production and blood viscosity, requiring close monitoring.
A client is admitted to the hospital with a diagnosis of infiltrating ductal carcinoma of the breast. Which expected manifestation should the nurse assess the client for?
- A. Bilateral palpable masses
- B. Pain in the breast and edema
- C. A fixed, irregularly shaped mass
- D. A round-shaped mass that is moveable
Correct Answer: C
Rationale: Infiltrating ductal carcinoma of the breast usually presents as a fixed, irregularly shaped mass. The mass is usually single and unilateral and is painless, nontender, and hard to the touch.
A client with a history of myocardial infarction is prescribed aspirin. What is the primary purpose of this medication?
- A. Reduce fever.
- B. Prevent platelet aggregation.
- C. Relieve chest pain.
- D. Lower cholesterol.
Correct Answer: B
Rationale: Aspirin prevents platelet aggregation, reducing the risk of thrombus formation in clients with a history of myocardial infarction.