Nokea
The nurse is caring for a client with a history of depression who is receiving sertraline (Zoloft) 50 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired all the time.
- B. I have trouble sleeping at night.
- C. I think about hurting myself sometimes.
- D. I have a dry mouth.
Correct Answer: C
Rationale: Thoughts of self-harm indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on sertraline. Options A, B, and D are common side effects of SSRIs (fatigue, insomnia, dry mouth) and less urgent.
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An adult has the following blood gasses: pH=7.52, pCO2=50, HCO3=35, and pO2=90. What is most likely to be in the client's history of presenting signs and symptoms?
- A. Persistent diarrhea
- B. Frequent vomiting
- C. Anxiety attack
- D. Emphysema
Correct Answer: B
Rationale: High pH and HCO3 indicate metabolic alkalosis, commonly caused by frequent vomiting, losing gastric acid.
A 53-year-old who has pernicious anemia is being seen in the physician's office. Because the client has pernicious anemia, which comment is of greatest concern to the nurse?
- A. I have been having trouble reading the newspaper.'
- B. I have pain up and down my legs.'
- C. My knees hurt when I climb stairs.'
- D. I am so tired of having a headache.'
Correct Answer: B
Rationale: Leg pain suggests worsening neuropathy, a serious complication of pernicious anemia, requiring urgent evaluation to prevent irreversible nerve damage.
A 16-year-old young woman is brought by her parents to the outpatient clinic for treatment of pelvic inflammatory disease (PID). While the nurse obtains a history, the client says bitterly, 'My parents are mean and don't really care about me.' Which of the following responses by the nurse is BEST?
- A. You feel your parents don't care about you?
- B. Your parents brought you to the clinic, didn't they?
- C. I am sure that your parents have your best interests at heart.
- D. Did you have a disagreement with your parents?
Correct Answer: A
Rationale: Reflecting the client’s feelings validates her emotions, encouraging therapeutic communication. Options B, C, and D are nontherapeutic, dismissing or challenging her statement.
The nurse is caring for a client who is receiving IV fluids at 125 mL/hour. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood pressure of 130/80 mmHg.
- B. Heart rate of 88 bpm.
- C. Respiratory rate of 24 breaths/min.
- D. Urine output of 100 mL/hour.
Correct Answer: C
Rationale: A respiratory rate of 24 breaths/min suggests fluid overload, a potential complication of IV fluids, possibly leading to pulmonary edema. Options A, B, and D are normal: blood pressure 130/80 mmHg, heart rate 88 bpm, and urine output 100 mL/hour indicate adequate hydration.
Following a diagnosis of acute glomerulonephritis (AGN) in their 6 year-old child, the parents remark: 'We just don't know how he caught the disease!' The nurse's response is based on an understanding that
- A. AGN is a streptococcal infection that involves the kidney tubules
- B. The disease is easily transmissible in schools and camps
- C. The illness is usually associated with chronic respiratory infections
- D. It is not 'caught' but is a response to a previous B-hemolytic strep infection
Correct Answer: D
Rationale: It is not 'caught' but is a response to a previous B-hemolytic strep infection. AGN is generally accepted as an immune-complex disease in relation to an antecedent streptococcal infection of 4 to 6 weeks prior.