Nokea
The nurse is assessing a client and suspects the client is experiencing DIC. Which of the following physical findings should the nurse anticipate?
- A. Xerostomia
- B. Bradycardia
- C. Epistaxis
- D. Hypertension
Correct Answer: C
Rationale: The correct answer is C: Epistaxis. Disseminated Intravascular Coagulation (DIC) is a condition where the body's clotting system is overactive, leading to both excessive clot formation and clot breakdown. Epistaxis, or nosebleeds, is a common physical finding in DIC due to the depletion of clotting factors and platelets. Xerostomia (A) is dry mouth and not typically associated with DIC. Bradycardia (B) is a slow heart rate, which is not a common finding in DIC as it usually presents with tachycardia. Hypertension (D) is increased blood pressure, which is not a typical physical finding in DIC.
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A nurse is providing teaching to a client who has hypothyroidism and has been prescribed levothyroxine. Which of the following medication instructions would the nurse include in the teaching?
- A. Take this medication before a meal or several hours after a meal.
- B. Take this medication during your morning meal.
- C. Take this medication with a full glass of water or fruit juice.
- D. Take this medication with high-protein foods.
Correct Answer: A
Rationale: The correct answer is A. Levothyroxine is best absorbed on an empty stomach, so taking it before a meal or several hours after a meal ensures optimal absorption. Taking it with food or certain beverages can interfere with absorption. Choice B is incorrect as taking it during a meal may reduce absorption. Choice C is incorrect as water or fruit juice is recommended, not required in full glass quantity. Choice D is incorrect as high-protein foods can also interfere with absorption.
A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized for treatment of the flu. During the night shift,the client is found climbing into the bed of another client who becomes upset and scared. Which of the following actions should the nurse take?
- A. Medicate the patient with antipsychotics.
- B. Assist the client to the correct room.
- C. Move the client to a room at the end of the hall.
- D. Place the client in restraints.
Correct Answer: B
Rationale: The correct answer is B: Assist the client to the correct room. This is the appropriate action as it addresses the immediate issue of the client being in the wrong room, which is causing distress to the other client. Moving the client to the correct room ensures safety and comfort for both clients. Medicating with antipsychotics (choice A) is not the first-line intervention in this situation and should be avoided unless absolutely necessary due to potential side effects. Moving the client to a room at the end of the hall (choice C) may not address the underlying issue and can isolate the client unnecessarily. Placing the client in restraints (choice D) should be avoided as it can be traumatic and is not indicated in this scenario.
A nurse in an acute mental health facility is creating a plan of care for a new client who has histrionic personality disorder. Which of the following is the highest priority for the nurse?
- A. Encourage client input in the treatment plan.
- B. Communicate with the client using concrete language.
- C. Demonstrate assertive behavior.
- D. Promote appropriate behavior during group therapy sessions.
Correct Answer: B
Rationale: The correct answer is B: Communicate with the client using concrete language. When working with a client with histrionic personality disorder, using concrete language helps to set clear boundaries and prevent misinterpretations. This is crucial in maintaining a therapeutic relationship and managing their behavior effectively. Encouraging client input (choice A) is important but not the highest priority in this case. Demonstrating assertive behavior (choice C) and promoting appropriate behavior in group therapy (choice D) are important but not as immediately crucial as clear communication.
A nurse is providing care to children on a general pediatric unit. Which of the following children should the nurse identify as a potential victim of abuse?
- A. A child whose parents answer questions for the child
- B. A child who has frequent visitors
- C. A child who has a BMI indicating obesity
- D. A child who uses the call light frequently
Correct Answer: A
Rationale: The correct answer is A. When parents answer questions for the child, it may indicate a lack of autonomy or control over their own care, suggesting potential abuse or neglect. This behavior can be a red flag for the nurse to further assess the child's situation. Choices B, C, and D do not necessarily indicate abuse. Frequent visitors could be a sign of social support, obesity may be due to various factors, and using the call light frequently may indicate medical needs rather than abuse. It is essential for the nurse to explore further if a child's autonomy is being compromised.
A nurse is performing an admission assessment on a client who has been diagnosed with schizophrenia. Which of the following findings should the nurse identify as a negative symptom?
- A. Bizarre behavior
- B. Waxy flexibility
- C. Somatic delusions
- D. Illogicality
Correct Answer: B
Rationale: Waxy flexibility reflects a lack of normal movement a negative symptom of schizophrenia.