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The nurse is caring for a client with a history of schizophrenia. Which medication is most likely to be prescribed?
- A. Fluoxetine (Prozac)
- B. Risperidone (Risperdal)
- C. Clonazepam (Klonopin)
- D. Bupropion (Wellbutrin)
Correct Answer: B
Rationale: Risperidone, an antipsychotic, is used to treat schizophrenia by managing hallucinations and delusions. Fluoxetine and bupropion are antidepressants, and clonazepam is for anxiety.
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A child sustains a supracondylar fracture of the femur. When assessing for vascular injury, the nurse should be alert for the signs of ischemia, which include:
- A. Bleeding, bruising, and hemorrhage
- B. Increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase
- C. Pain, pallor, pulselessness, paresthesia, and paralysis
- D. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus
Correct Answer: C
Rationale: Bleeding, bruising, and hemorrhage may occur due to injury but are not classic signs of ischemia. An increase in serum levels of creatinine, alkaline phosphatase, and aspartate transaminase is related to the disruption of muscle integrity. Classic signs of ischemia related to vascular injury secondary to long bone fractures include the five 'P's': pain, pallor, pulselessness, paresthesia, and paralysis. Generalized swelling, pain, and diminished functional use with muscle rigidity and crepitus are common clinical manifestations of a fracture but not ischemia.
Which meal selection is most appropriate for a patient with iron deficiency anemia?
- A. Roast turkey,gelatin,green beans
- B. Chicken salad, sandwich,coleslaw,French fries
- C. Egg salad on wheat bread,carrot sticks ,spinach and kale salad
- D. Pork chop,mashed potatoes,green peas
Correct Answer: C
Rationale: Spinach and kale are rich in iron ,which is essential for correcting iron deficiency anemia. The other meal options do not contain significant iron-rich foods making them less appropriate for this condition.
The nurse is caring for a client with a history of Addison’s disease. The nurse should expect the client to have:
- A. Hypotension
- B. Hypertension
- C. Hyperglycemia
- D. Weight gain
Correct Answer: A
Rationale: Addison’s disease causes adrenal insufficiency, reducing cortisol and aldosterone, leading to hypotension due to fluid and sodium loss.
A client admitted to the psychiatric unit claims to be the Pope and insists that he will not be kept away from his followers. The most likely explanation for the client's delusion is:
- A. A reaction formation
- B. A stressful event
- C. Low self-esteem
- D. Overwhelming anxiety
Correct Answer: C
Rationale: Delusions of grandeur, like claiming to be the Pope, often stem from low self-esteem in psychiatric disorders like schizophrenia, compensating for feelings of inadequacy. The other factors are less specific.
The client is admitted with a diagnosis of acute respiratory distress syndrome (ARDS). Which intervention should the nurse anticipate?
- A. Mechanical ventilation
- B. Nebulizer treatments
- C. Chest physiotherapy
- D. Antibiotic therapy
Correct Answer: A
Rationale: ARDS causes severe hypoxemia, often requiring mechanical ventilation to maintain oxygenation. Nebulizers, physiotherapy, and antibiotics are secondary or condition-specific.