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If the client snorts cocaine on a regular basis, which physical assessment findings will the nurse most likely find? Select all that apply.
- A. Dry, stuffy nose
- B. Perforated nasal septum
- C. Hoarseness and cough
- D. Sinus pain under the eyes
- E. Elevated blood pressure
- F. Inability to sleep
Correct Answer: A,B,D,E,F
Rationale: Regular cocaine snorting causes nasal irritation, septal damage, sinus pain, hypertension, and insomnia due to its stimulant effects.
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Which findings strongly suggest that the client is experiencing an exacerbation of the bipolar disorder? Select all that apply.
- A. The client has been spending money extravagantly.
- B. The client has been avoiding social activities.
- C. The client has been methodically cleaning the house.
- D. The client has been staying up late to read.
- E. The client demonstrates increased sexual promiscuity.
- F. The client has increased anxiety when going outside the house.
Correct Answer: A,E
Rationale: Extravagant spending and sexual promiscuity are indicative of mania, a key feature of bipolar disorder exacerbation.
The client who sustained a brain injury from an MVA is now experiencing aggression impulsivity and poor judgment. In teaching the family which area of the brain illustrated should the nurse identify as being affected?
- A. Line A
- B. Line B
- C. Line C
- D. Line D
Correct Answer: B
Rationale: The prefrontal cortex (Line B) modulates judgment aggression and impulsivity. Cortex (A) controls motor functions hypothalamus (C) regulates temperature/fluids and cerebellum (D) manages balance. image4.png
Which technique is most therapeutic for helping clients with dementia remain oriented?
- A. Address all clients using their first name.
- B. Ask clients to identify their goals for the day.
- C. Assign clients to greet visitors each day.
- D. Post large calendars with the current date.
Correct Answer: D
Rationale: Large calendars provide a constant visual cue, aiding orientation to time in clients with dementia.
Which approach is best for managing the client's care?
- A. Use a nonjudgmental manner when cleaning the client of stool.
- B. Ask the client's spouse to perform hygiene measures.
- C. Hold the client responsible for all hygiene.
- D. Assign same-gender nurses to care for the client.
Correct Answer: A
Rationale: A nonjudgmental approach preserves the client's dignity, reducing embarrassment and supporting self-esteem during hygiene care.
What is the most appropriate nursing action when the terminally ill client's death is imminent?
- A. Stay with the client and contact the family.
- B. Notify the hospital chaplain of the potential for death.
- C. Call the funeral home, alerting them of an imminent death.
- D. Transfer the client to the intensive care unit.
Correct Answer: A
Rationale: Staying with the client provides comfort, and contacting family ensures support, aligning with the advance directive.