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The nurse is assessing a client who reports using cocaine several times in the past week. Which observations should the nurse expect on assessment?
- A. Stimulation and dilated pupils
- B. Bradycardia and bradypnea
- C. Hallucinations and delusions
- D. Lethargy and depression
Correct Answer: A
Rationale: Cocaine use typically results in stimulation of the central nervous system, leading to increased heart rate, dilated pupils, and heightened alertness. Bradycardia and bradypnea are not typical, as cocaine causes tachycardia and increased respiratory rate. Hallucinations and delusions are more associated with hallucinogens or psychotic disorders. Lethargy and depression occur during the 'crash' phase, not the immediate effects of cocaine use.
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An adult female client is brought to the Emergency Center after fainting at work. The nurse completes an assessment of the client and identifies caregiver role strain as a nursing problem. Which information best supports this problem?
- A. Cares for an older parent and her children
- B. Anxious to leave for personal appointments
- C. Takes naps in her car during lunch hour
- D. Works an average of 60 hours per week
Correct Answer: A
Rationale: Caring for an older parent and children simultaneously indicates significant caregiver role strain due to increased responsibilities. Anxiety, napping, and long work hours suggest stress but are less specific to caregiving demands.
A preschool-aged girl tells the school nurse that her hair hurts. The nurse finds that the child's hair has been arranged to cover several small bald spots. Which finding indicates to the nurse that the hair loss is not disease related?
- A. Episodic intervals of pruritus
- B. Erythema of the localized lesions
- C. Ecchymotic blood accumulations
- D. Evidence of patches of lost hair
Correct Answer: C
Rationale: Ecchymotic blood accumulations suggest trauma, such as hair-pulling (e.g., trichotillomania), indicating a non-disease-related cause. Pruritus and erythema suggest dermatological issues. Patches of hair loss alone do not specify the cause.
An adolescent who was arrested a month ago for gang-related activities has a court order to attend weekly group therapy sessions at the mental health clinic. Today the adolescent's mother calls the clinic nurse to report that her child became angry last night and put a fist through a window. Which intervention is most important for the nurse to implement?
- A. Reinforce the need for the adolescent to attend group therapy sessions
- B. Tell the mother to describe her feelings of helplessness to her child
- C. Advise the mother to call the police if violent behavior occurs again
- D. Refer the mother for psychiatric evaluation for anxiety and depression
Correct Answer: C
Rationale: Advising the mother to call the police if violent behavior recurs prioritizes safety for the adolescent and household. Therapy attendance is important but secondary to immediate safety. Discussing the mother's feelings or referring her for evaluation does not address the acute risk.
Mark which behaviors might be related to alcohol intoxication, acute phase of rape-trauma syndrome, or both. Tick only 1 box.
- A. Numbness: Rape-trauma syndrome
- B. Poor decision making: Alcohol intoxication
- C. Crying: Both
- D. Disbelief: Rape-trauma syndrome
- E. Irritability: Alcohol intoxication
- F. Difficulty concentrating: Both
Correct Answer: C
Rationale: Crying occurs in both alcohol intoxication (due to disinhibition) and rape-trauma syndrome (due to emotional distress). Numbness and disbelief are specific to rape-trauma syndrome. Poor decision making, irritability, and difficulty concentrating are typical of alcohol intoxication, though the latter can also occur in rape-trauma syndrome.
In conducting the initial assessment of a preoperative client, the nurse notes that the client's home medications include the monoamine oxidase (MAO) inhibitor phenelzine. Because of this client's medication history, which assessment finding is most important for the nurse to monitor?
- A. Blood pressure
- B. Urinary output
- C. Respiratory rate
- D. Temperature
Correct Answer: A
Rationale: MAO inhibitors like phenelzine can cause hypertensive crises, especially with certain foods or medications. Monitoring blood pressure is critical to detect this life-threatening complication. Urinary output, respiratory rate, and temperature are less directly affected by MAO inhibitors.