Nokea
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. Bradycardia and bradypnea.
- B. Stimulation and dilated pupils.
- C. Hallucinations and delusions.
- D. Lethargy and depression.
Correct Answer: B
Rationale: Cocaine, a stimulant, typically causes stimulation, increased heart rate, and dilated pupils. Bradycardia/bradypnea, hallucinations/delusions, or lethargy/depression are less common or associated with withdrawal/overdose.
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The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?
- A. Sweet potatoes.
- B. Spinach salad.
- C. Bananas.
- D. Fish.
Correct Answer: B
Rationale: Spinach is high in oxalates, contributing to calcium oxalate stone formation. Sweet potatoes, bananas, and fish are generally safe.
The nurse is using the CAGE questionnaire as a screening tool for a client who is seeking help because his wife said he had a drinking problem. Which information should the nurse explore in-depth with the client based on this screening tool?
- A. Cancer screening results, anger, gastritis, daily alcohol intake.
- B. Consumption, liver enzyme, gastrointestinal complaints, and bleeding.
- C. Efforts to cut down, annoyance with questions, guilt, and drinking as an 'Eye-opener.'
- D. Minimizes drinking, frequently misses family events, guilt about drinking, and amount of daily intake.
Correct Answer: C
Rationale: The CAGE questionnaire assesses alcohol dependency through efforts to cut down, annoyance, guilt, and eye-opener drinking, which should be explored in-depth.
A middle-aged adult with major depressive disorder suffers from psychomotor retardation, hypersomnia, and motivation. Which intervention is likely to be most effective in returning this client to a normal level of functioning?
- A. Teach the client to develop a plan for daily structured activities.
- B. Encourage the client to exercise.
- C. Suggest that the client develop a list of pleasurable activities.
- D. Provide education on methods to enhance sleep.
Correct Answer: A
Rationale: Structured daily activities provide purpose and combat psychomotor retardation and lack of motivation, key to restoring function.
A client is admitted to the mental health unit and sits in the corner of the day room. When the nurse begins the admission assessment interview, the client is guarded, suspicious, and resists talking. Which action should the nurse implement?
- A. Postpone the client interview until the next day.
- B. Document the client's paranoid behavior.
- C. Attempt to ask the client simple questions.
- D. Ask another nurse to talk with the client.
Correct Answer: C
Rationale: Attempting to ask the client simple questions is a non-threatening approach that allows the nurse to start the assessment and establish rapport. Postponing delays care, documenting should follow engagement, and involving another nurse is a later option.
Laboratory Test
Result
Glucose
75 mg/dL (4.2 mmol/L)
Reference Range
74 to 106 mg/dim (4.1 to 5.9 mmol/L)
Click to highlight the assessment findings that require IMMEDIATE follow-up by the nurse. The client is a 68-year-old with a history of diabetes, hypertension (HTN), coronary artery disease (CAD), and recently diagnosed with end-stage renal disease (ERSD). She has been on hemodialysis three times a week for one month and presents to the emergency department (ED) with: Fatigue, Generalized weakness, Muscle cramps, Tingling sensation in her arms and legs, Lightheadedness. She also reports having missed her scheduled dialysis for the past 2 days, coupled with complaints of nausea, poor appetite, and an inability to attend the dialysis sessions.
- A. Muscle cramps
- B. Tingling sensation in her arms and legs
- C. Lightheadedness
- D. Fatigue
- E. Generalized weakness
Correct Answer: A,B,C
Rationale: Muscle cramps, tingling sensation, and lightheadedness are signs of electrolyte imbalance, likely due to missed dialysis, which can lead to serious complications like cardiac arrhythmias. The nurse should monitor vital signs, neurological status, and notify the physician.