Nokea
The nurse caring for a client prescribed clozapine reviews the client's laboratory studies. Which laboratory study is the priority to monitor for an adverse effect associated with the use of this medication?
- A. Platelet count
- B. Cholesterol level
- C. Blood urea nitrogen
- D. White blood cell count
Correct Answer: D
Rationale: Hematological reactions can occur in the client taking clozapine, an atypical antipsychotic, and include agranulocytosis and mild leukopenia. The white blood cell count should be assessed before initiating treatment and should be monitored closely during the use of this medication. The client should also be monitored for signs indicating agranulocytosis, which may include sore throat, malaise, and fever. The remaining options are unrelated to the use of this medication.
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The nurse is assessing a client with a suspected diverticulitis. Which of the following findings is most indicative of this condition?
- A. Left lower quadrant pain.
- B. Right upper quadrant pain.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A
Rationale: Left lower quadrant pain is a hallmark sign of diverticulitis due to inflammation of diverticula in the sigmoid colon.
The mother of a newborn is concerned about the number of persons with heart disease in her family. She asks the nurse when she should start her baby on a low fat, low cholesterol diet to lower the risk of heart disease, the nurse should tell her to start diet modifications:
- A. At birth.
- B. At age 2.
- C. At age 5.
- D. At age 10.
Correct Answer: B
Rationale: Diet modifications for heart disease prevention, such as low-fat, low-cholesterol diets, are generally recommended to begin at age 2, when children transition to a more varied diet.
The nurse is caring for a client with a history of burns covering 25% of the body. Which of the following interventions should be included in the plan of care? Select all that apply.
- A. Monitor for signs of infection.
- B. Administer I.V. fluids as prescribed.
- C. Apply silver sulfadiazine to burns.
- D. Provide a low-protein diet.
- E. Administer analgesics as needed.
Correct Answer: A, B, C, E
Rationale: Monitoring for infection, I.V. fluids, silver sulfadiazine, and analgesics are essential for burn care. A high-protein diet is needed, not low-protein.
A client with severe major depression states, 'My heart has stopped and my blood is black ash.' The nurse interprets this statement to be evidence of which of the following?
- A. Hallucination.
- B. Illusion.
- C. Delusion.
- D. Paranoia.
Correct Answer: C
Rationale: The client's statement reflects a false, fixed belief that is not based in reality, which is characteristic of a delusion. Hallucinations involve sensory perceptions, illusions are misinterpretations of stimuli, and paranoia involves suspicion, none of which fit this scenario.
The nurse is planning a continuous quality improvement (CQI) process to decrease the infection rate on the nursing unit. The nurse should consider which of the following when planning the process? Select all that apply.
- A. CQI processes are required by accrediting agencies
- B. The approach to CQI can be retrospective or concurrent
- C. Institutional Review Board (IRB) approval is required
- D. CQI is conducted by people who are not part of the process
- E. The CQI process has a fixed endpoint
Correct Answer: A,B
Rationale: CQI is often required by accrediting agencies and can be retrospective or concurrent. IRB approval is not typically needed, CQI involves unit staff, and it is ongoing without a fixed endpoint.