Nokea
The nurse is caring for a client with a diagnosis of schizophrenia. Which of the following statements is MOST descriptive of the affect of a patient with schizophrenia?
- A. The client answers all questions with one word.
- B. The client laughs while talking about being raped.
- C. The client exhibits no energy or interest in tasks.
- D. The client cries while talking about mother's death.
Correct Answer: B
Rationale: inappropriate affect, expression of feelings bizarre for situation
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The homecare nurse is visiting an infant who had a myelomeningocele repair.
The homecare nurse determines that the parents are accepting of their infant if which of the following is observed?
- A. The parents state that the infant will outgrow this problem in time.
- B. The parents ask a neighbor to perform bladder expression.
- C. The parents measure the head circumference daily.
- D. The parents relate that they believe the child will walk in one year.
Correct Answer: C
Rationale: Strategy: Think about each statement and how it relates to myelomeningocele. (1) child has a chronic problem (2) indicates the parents' lack of interest and inability to care for the child (3) correct-parents' participation in care may be first sign of acceptance; head circumference measurement is important due to risk of hydrocephalus following surgery; even simple care like bathing child could bring acceptance (4) shows a lack of understanding about myelomeningocele
A 36-year-old man has a flaccid bladder following a spinal cord injury. The nurse is teaching the client about dietary changes. Which of the following beverages, if selected by the client, would indicate to the nurse that teaching was effective?
- A. Lemonade.
- B. Prune juice.
- C. Milk.
- D. Orange juice.
Correct Answer: B
Rationale: promotes acidic urine, minimizes risk of urinary tract infection and stone formation, also use cranberry, tomato juice, bouillon
The nurse is caring for a client in her third trimester of pregnancy. The nurse is MOST concerned by which of the following assessments?
- A. The client complains of epigastric pain.
- B. The client complains of shortness of breath.
- C. The client states she has increased rectal pressure.
- D. The client has gained of 33 pounds during her pregnancy.
Correct Answer: A
Rationale: is usually indicative of an impending convulsion
The nurse is caring for a client who is receiving a continuous IV infusion of dopamine for hypotension. Which of the following findings would be of GREATest concern to the nurse?
- A. Heart rate of 100 bpm.
- B. Blood pressure of 90/60 mmHg.
- C. Urine output of 20 mL/hour.
- D. Respiratory rate of 18 breaths/min.
Correct Answer: C
Rationale: Urine output of 20 mL/hour indicates oliguria, a serious complication of dopamine, suggesting inadequate renal perfusion despite treatment for hypotension. Options A, B, and D are less concerning: heart rate 100 bpm and blood pressure 90/60 mmHg are expected, and respiratory rate 18 breaths/min is normal.
The nurse is caring for a patient hospitalized with an acute asthma attack. The nurse would be MOST concerned if which of the following was observed?
- A. The patient becomes more diaphoretic.
- B. The patient's respirations increase from 14 to 16 per minute.
- C. The patient's pulse increases from 86 to 100 beats per minute.
- D. The patient shows increasing pallor.
Correct Answer: C
Rationale: pulse increases due to decrease in oxygenation of tissues