Nokea
The nurse assesses a client who has been re-admitted to the psychiatric inpatient unit for schizophrenia. His symptoms have been managed for several months with fluphenazine (Prolixin). Which should be a focus of the first assessment?
- A. Stressors in the home
- B. Medication compliance
- C. Exposure to hot temperatures
- D. Alcohol use
Correct Answer: B
Rationale: Medication compliance. Ensuring adherence to fluphenazine is critical for symptom management in schizophrenia.
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An adult client is found to be unresponsive on morning rounds. After checking for responsiveness and calling for help, the next action that should be taken by the nurse is to:
- A. check the carotid pulse
- B. deliver 5 abdominal thrusts
- C. give 2 rescue breaths
- D. ensure an open airway
Correct Answer: D
Rationale: According to the ABCs of CPR, the first step in rescuing an unresponsive victim after checking responsiveness and calling for help is to open the victim's airway.
The nurse has reinforced teaching with a client with newly diagnosed psoriasis. Which of the following statements by the client would require follow-up?
- A. Exposure to sunlight will worsen my psoriasis.
- B. I should avoid scratching the lesions.
- C. Stress can worsen my psoriasis.
- D. I should avoid drinking alcohol.
Correct Answer: A
Rationale: Moderate sunlight exposure can improve psoriasis, so statement A is incorrect and requires follow-up. Avoiding scratching (B), recognizing stress as a trigger (C), and avoiding alcohol (D) are accurate and align with psoriasis management.
A client was admitted to the psychiatric unit after refusing to get out of bed. In the hospital the client talks to unseen people and voids on the floor. The nurse could best handle the problem of voiding on the floor by
- A. Requiring the client to mop the floor
- B. Restricting the client's fluids throughout the day
- C. Withholding privileges each time the voiding occurs
- D. Toileting the client more frequently with supervision
Correct Answer: D
Rationale: Toileting the client more frequently with supervision. This approach addresses the physical need in a client with altered thought processes.
The nurse is assessing the deep tendon reflexes of a client with preeclampsia. Which method is used to elicit the biceps reflex?
- A. The nurse places her thumb on the muscle inset in the antecubital space and taps the thumb briskly with the reflex hammer.
- B. The nurse loosely suspends the client's arm in an open hand while tapping the back of the client's elbow.
- C. The nurse instructs the client to dangle her legs as the nurse strikes the area below the patella with the blunt side of the reflex hammer.
- D. The nurse instructs the client to place her arms loosely at her side as the nurse strikes the muscle insert just above the wrist.
Correct Answer: A
Rationale: To elicit the biceps reflex, the nurse places her thumb on the biceps tendon in the antecubital space and taps it with a reflex hammer, so A is correct. Answer B is incorrect as it describes a different technique. Answer C refers to the patellar reflex, and Answer D is not a standard method for the biceps reflex.
The nurse is reinforcing education about home care to the parent of a 10-year-old with cystic fibrosis. Which of the following statements by the parent indicates that teaching has been effective? Select all that apply.
- A. Chest physiotherapy is administered only if respiratory symptoms worsen.
- B. I will give my child pancreatic enzymes with all meals and snacks.
- C. I will increase my child's salt intake during hot weather.
- D. Our child will need a high-carbohydrate, high-protein diet.
- E. We will limit our child's participation in sports activities.
Correct Answer: B,C,D
Rationale: Pancreatic enzymes with meals (B), increased salt in hot weather (C), and a high-calorie, high-protein diet (D) are correct for cystic fibrosis management. Chest physiotherapy (A) is routine, not symptom-based, and limiting sports (E) is unnecessary unless advised.