Nokea
The nurse is caring for the client 4 days after admission. For each finding below, click to specify if the finding indicates that the client's status is improving or concerning.
- A. Client ate 80% of the meals and took a shower today.
- B. Client is seen joining group activities in the day room.
- C. Client states, "I feel more energetic today than I have in many months."
- D. Client is seen handing a personal watch and photo album to another client.
- E. Client reports depression 0/10 and states, "I feel a lot better. I think I know what I need to do now."
Correct Answer:
Rationale: Participation in group activities, increased appetite, and performing self-hygiene (eg, showering) indicate an
improvement in the client's status because the client was previously withdrawn with little interest in interacting with others or
performing self-care (eg, declining breakfast tray, body odor).
During the early phase of therapy with antidepressants (eg, selective serotonin reuptake inhibitors [escitalopram]), the risk of
suicide may increase because clients can become more energized as the depression lifts, enabling them to carry out previous
suicide plans. The nurse should find concerning the client's statements about feeling more energized and "knowing what to
do now," which can indicate that the client has determined a plan for suicide and is at peace knowing the plan.
Giving away meaningful possessions (eg, watch, photo album) is concerning for an impending suicide attempt. The nurse
should ask directly about thoughts of suicide.
You may also like to solve these questions
Which of the following findings indicate that the client is improving as expected? Select all that apply.
- A. Blood pressure 138/70 mm Hg
- B. Clear lung sounds
- C. Increased urinary output
- D. SpO, 95% on room air
- E. Unilateral lower extremity edema
Correct Answer: A,B,C,D
Rationale: Clinical improvement in a client with heart failure includes manifestations of reduced cardiac workload and improved fluid
volume status and gas exchange. A decrease in blood pressure from 170/100 mm Hg to 138/70 mm Hg and increased
urinary output indicate effectiveness of diuretics to reduce circulatory fluid volume and antihypertensive medications to
decrease cardiac workload . In addition, clear lung sounds and an increased capillary oxygen
saturation (SpO2) indicate a decrease in pulmonary congestion and an improvement in fluid volume status
Which of the following statements by the client's parent indicates a correct understanding of the teaching about management for type 1 diabetes mellitus? Select all that apply
- A. I may need to administer insulin more frequently when my child is ill
- B. Insulin requirements will change as my child grows
- C. Insulin should be injected deeply enough to reach the muscle
- D. Overnight social events should be avoided to prevent changes in my child's routine
- E. Proper diet and exercise can eliminate the need for insulin during adulthood.
Correct Answer: A,B
Rationale: Clients with type 1 diabetes mellitus (DM) have impaired insulin production due to autoimmune destruction of pancreatic beta
cells. Because clients with type 1 DM do not produce insulin, lifelong insulin replacement is required. Insulin requirements
will change with growth and development
Insulin requirements may increase because stressful events (eg, illness) cause blood glucose levels to rise. When the
client is ill, the parent should be instructed to notify the health care provider, monitor blood glucose levels closely, test the urine
for ketones, increase insulin administration per sliding scale, and monitor for signs of dehydration
The client is newly prescribed aripiprazole for autism spectrum disorder. The nurse is reinforcing teaching to the client's parents. Which statement by the nurse is appropriate?
- A. Abruptly stopping the medication can cause withdrawal symptoms
- B. Aripiprazole will cure your child's autism.
- C. Restlessness is an expected side effect and will eventually subside.
- D. This medication will eliminate your child's self-harm behaviors
Correct Answer: A
Rationale: Aripiprazole, an atypical antipsychotic medication, is used in the treatment of irritability associated with autism spectrum
disorder (ASD), schizophrenia, bipolar disorder, and other mental health disorders. Aripiprazole works as a partial agonist at
the serotonin and dopamine receptor sites. As a result, the medication has a more favorable safety profile (eg, fewer metabolic
effects, lower potential for prolactin release) than other antipsychotics; however, it may be less effective in symptom relief.
Clients taking aripiprazole should be reminded to not abruptly stop taking the medication because it can cause withdrawal
symptoms (eg, anxiety, dizziness, tachycardia, diaphoresis, insomnia, vomiting) and may exacerbate previous symptoms.
These medications should be weaned over time and substituted with an alternate medication under the supervision of a health
care provider
The nurse is caring for a 65-year-old client in the clinic. Complete the following sentence by choosing from the list of options.The nurse suspects that the clients condition is most likely related to the abrupt discontinuation of-----------------
- A. Lisinopril
- B. Metoprolol
- C. Atorvastatin
Correct Answer: B
Rationale: Beta-adrenergic antagonists, also known as beta blockers (eg, metoprolol, atenolol), are commonly used to treat
hypertension, heart failure, and anxiety. Beta blockers reduce cardiac workload by inhibiting the action of catecholamines (eg,
epinephrine, norepinephrine) on beta-adrenergic receptors in the heart. This slows electrical conduction through the heart,
which decreases heart rate and blood pressure.
Abrupt discontinuation of beta blockers can result in rebound hypertension, angina, palpitations, myocardial infarction,
arrhythmias (eg, tachycardia, ventricular tachycardia), or sudden death. These discontinuation-associated risks are caused
by increased beta-adrenergic receptor sensitivity to circulating catecholamines, resulting in an increased sympathetic
response. Withdrawal symptoms should resolve after resumption of the medication.
Complete the following sentence by choosing from the lists of options. The nurse should first address the client's -------followed by the client's --------------
- A. Hypovolemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hyperglycemia
Correct Answer: A,D
Rationale: Hyperglycemia in diabetic ketoacidosis (DKA) causes osmotic diuresis that leads to severe dehydration. When hyperglycemia exceeds the
renal threshold of glucose absorption, glucosuria (excretion of glucose in urine) occurs. Water loss is increased due to osmotic diuresis
induced by glucosuria, and extreme dehydration, hypotension, and decreased organ perfusion occur.
The priority intervention in DKA is to initiate an IV fluid bolus with 0.9% sodium chloride followed by insulin administration to lower serum
glucose levels. Rapid fluid resuscitation should occur before insulin infusion because insulin shifts water, potassium, and glucose into the
cells, worsening extracellular dehydration and electrolyte imbalances. Therefore, for clients with DKA, the nurse should first address
hypovolemia followed by hyperglycemia.