Nokea
The chart of a client with schizophrenia states that the client has echolalia. The nurse can expect the client to:
- A. Speak using words that rhyme
- B. Repeat words or phrases used by others
- C. Include irrelevant details in conversation
- D. Make up new words with new meanings
Correct Answer: B
Rationale: Echolalia in schizophrenia involves repeating words or phrases spoken by others, reflecting impaired communication processing.
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The nurse is caring for a client with end-stage kidney disease. The client says, 'I have decided that I don't want any more dialysis or treatments. This is just prolonging the inevitable.' The nurse responds, 'You have every right to do so. I will notify the nephrologist of your wishes.' Which ethical principle is being demonstrated by the nurse?
- A. justice
- B. fidelity
- C. autonomy
- D. beneficence
Correct Answer: C
Rationale: Respecting the client’s decision to refuse treatment demonstrates autonomy, prioritizing their right to self-determination.
The nurse is preparing to administer a dose of warfarin (Coumadin) to a client. The client’s international normalized ratio (INR) is 4.5. Which of the following actions should the nurse take?
- A. Administer the dose as ordered.
- B. Withhold the dose and notify the physician.
- C. Administer vitamin K as a reversal agent.
- D. Recheck the INR in 4 hours.
Correct Answer: B
Rationale: an INR of 4.5 is above the therapeutic range (2.0–3.0), indicating a risk of bleeding; the dose should be withheld and the physician notified
The RN on the oncology unit is preparing to mix and administer amphoteracin B (Fungizone) to a client. Which action is contraindicated for administering this drug IV?
- A. Mix the drug with normal saline solution
- B. Administer the drug over 4-6 hours
- C. Hydrate with IV fluids 2 hours before the infusion
- D. Premedicate the client - acetaminophen (Tylenol) and diphenhydramine (Benadryl)
Correct Answer: A
Rationale: Amphotericin B should not be mixed with normal saline due to precipitation risk; it requires dextrose solutions. Slow administration, hydration, and premedication are standard to reduce side effects.
The nurse caring for a client with a suspected peptic ulcer recognizes which exam as the one most reliable in diagnosing the disease?
- A. Upper-gastrointestinal x-ray
- B. Gastric analysis
- C. Endoscopy
- D. Barium studies
Correct Answer: C
Rationale: Endoscopy directly visualizes the gastric mucosa, allowing for biopsy and definitive diagnosis of a peptic ulcer, making it the most reliable method.
The nurse is providing discharge teaching for a client taking dissulfiram (Antabuse). The nurse should instruct the client to avoid eating:
- A. Peanuts, dates, raisins
- B. Figs, chocolate, eggplant
- C. Pickles, salad with vinaigrette dressing, beef
- D. Milk, cottage cheese, ice cream
Correct Answer: C
Rationale: Vinaigrette may contain alcohol, which reacts with disulfiram, causing severe symptoms.