Nokea
The nurse is caring for a client with major depressive disorder. Which of the following findings would be consistent with the condition?
- A. hypervigilance and intrusive memories
- B. impulsivity and intense fear of abandonment
- C. changes in appetite and personal hygiene
- D. extreme shyness and hypersensitivity to criticism
Correct Answer: C
Rationale: Major depressive disorder is characterized by symptoms such as changes in appetite, sleep disturbances, and neglect of personal hygiene due to low energy and motivation.
You may also like to solve these questions
Which of the following indicates failure of a ventriculoperitoneal shunt?
- A. Projectile vomiting
- B. Abdominal distention
- C. Decreased urinary output
- D. Hemodilution
Correct Answer: A
Rationale: Projectile vomiting is a sign of increased intracranial pressure due to ventriculoperitoneal shunt failure, indicating obstruction or malfunction.
The nurse is caring for a client who had a surgical excision and biopsy of a tumor. The biopsy results show that the tumor is malignant, but the client has not yet been informed by the health care provider. The client asks the nurse, 'Am I going to die?' Which of the following responses would be appropriate for the nurse to make?
- A. You seem upset. Tell me more about how you are feeling about this situation.
- B. I understand that you feel anxious. Maybe watching television will help you relax.
- C. Waiting for test results can be very stressful. I am sure that it will all work out.
- D. The biopsy results show that you have cancer. However, many cancers are treatable.
Correct Answer: A
Rationale: Exploring the client's feelings is supportive and appropriate, as the nurse should not disclose results before the provider.
An adult is admitted with advanced cancer of the GI tract. What question must be included in the admission assessment?
- A. What foods do you like best?
- B. Do you have advance directives?
- C. Do you want CPR if you go into cardiac arrest?
- D. Do you understand the serious nature of your illness?
Correct Answer: B
Rationale: Advanced cancer requires discussion of end-of-life preferences. Asking about advance directives ensures the client's wishes are documented, taking priority over dietary preferences, specific CPR desires, or illness understanding.
The pediatric nurse receives report on 4 clients. Which client should the nurse see first?
- A. A 2-month-old awaiting evaluation for possible hip dislocation; parents are at the bedside
- B. A 6-year-old just returned from a bronchoscopy; a parent is at the bedside
- C. A 7-year-old just returned from a non-contrast abdominal CT scan; no parents are at the bedside
- D. An 11-year-old scheduled for ear surgery today, no parents are at the bedside
Correct Answer: B
Rationale: The 6-year-old post-bronchoscopy is at risk for airway complications and requires immediate assessment.
A 2 year-old child has recently been diagnosed with cystic fibrosis. The nurse is teaching the parents about home care for the child. Which of the following information is appropriate for the nurse to include?
- A. Allow the child to continue normal activities
- B. Schedule frequent rest periods
- C. Limit exposure to other children
- D. Restrict activities to inside the house
Correct Answer: A
Rationale: Allow the child to continue normal activities. Physical activity supports autonomy and mucus secretion in cystic fibrosis.