Nokea
The nurse is caring for a client with a history of depression who is receiving venlafaxine (Effexor) 75 mg PO bid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel tired in the afternoon.
- B. I have a dry mouth.
- C. I think about hurting myself.
- D. I take my medication with food.
Correct Answer: C
Rationale: Thoughts of hurting oneself indicate suicidal ideation, a medical emergency requiring immediate intervention in a client on venlafaxine. Options A, B, and D are less concerning: fatigue and dry mouth are common side effects, and taking with food is acceptable.
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The mother of a 3-month-old infant tells the nurse that her child has a bumpy rash over most of his body. What is likely to be initially ordered for this child?
- A. Skin biopsy
- B. Stool specimen
- C. CBC with differential
- D. Elimination diet
Correct Answer: D
Rationale: A bumpy rash in a 3-month-old suggests possible food allergies; an elimination diet is a non-invasive initial approach to identify triggers, unlike biopsy, stool, or CBC.
In planning care for a child diagnosed with minimal change nephrotic syndrome, the nurse should understand the relationship between edema formation and
- A. Increased retention of albumin in the vascular system
- B. Decreased colloidal osmotic pressure in the capillaries
- C. Fluid shift from interstitial spaces into the vascular space
- D. Reduced tubular reabsorption of sodium and water
Correct Answer: B
Rationale: Decreased colloidal osmotic pressure in the capillaries. Loss of albumin reduces osmotic pressure, causing edema.
A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse.
- A. What symptoms should the nurse expect in a client with type I diabetes and a blood sugar of 50 mg/dL?
- B. Confused with cold, clammy skin and a pulse of 110.
- C. Lethargic with hot, dry skin and rapid, deep respirations.
- D. Alert and cooperative with a BP of 130/80 and respirations of 1
- E. Short of breath, with distended neck veins and a bounding pulse of 96.
Correct Answer: A
Rationale: A blood sugar of 50 mg/dL indicates hypoglycemia, characterized by confusion, cold, clammy skin, and tachycardia (pulse 110) due to sympathetic activation. Hyperglycemia causes hot, dry skin and rapid respirations, while normal or fluid overload symptoms do not apply.
After receiving an annual influenza immunization, a client develops symptoms suggestive of Guillain-Barré syndrome. Which symptom is associated with Guillain-Barré syndrome?
- A. Paresthesia and weakness of the lower extremities
- B. Hyperactive deep tendon reflexes
- C. Emotional lability
- D. Flapping tremors of the hand and feet
Correct Answer: A
Rationale: Guillain-Barré syndrome causes paresthesia and weakness in the lower extremities , progressing upward. Reflexes are hypoactive (B is incorrect). Emotional lability and tremors are not typical.
The nurse is caring for an aging client. Which statement the client makes indicates that he is having difficulty with the developmental tasks of aging?
- A. I like to make toys for my grandchildren.'
- B. I used to be a farmer, but now I can't do all that hard work.'
- C. I wish I had changed careers when I really wanted to; now it's too late.'
- D. We don't have as much money now as we did before I retired.'
Correct Answer: C
Rationale: Regret over unfulfilled career changes reflects difficulty achieving ego integrity, the developmental task of accepting one's life. Other statements show adaptation or acceptance.