Nokea
The nurse is interviewing a client with clinical depression. Which of the following risk factors would the nurse expect to find in the client's history? Select all that apply.
- A. normal childhood
- B. family history of depression
- C. recent major life change
- D. Lipitor used to treat high blood pressure
Correct Answer: B, C
Rationale: Family history of depression and recent major life changes are known risk factors for clinical depression. A normal childhood is not a risk factor, and Lipitor treats cholesterol, not blood pressure.
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The nurse is evaluating nutritional outcomes for a client with anorexia nervosa. Which one of the following is the most objective favorable outcome for the client?
- A. The client eats all the food on her tray
- B. The client requests that family bring special foods
- C. The client's weight has increased
- D. The client weighs herself each morning
Correct Answer: C
Rationale: Weight gain is the most objective and measurable outcome for anorexia nervosa, indicating improved nutritional status and progress toward recovery.
The nurse is admitting a client with a diagnosis of severe malignant catatonia to the in-patient psychiatric unit. Under which condition would the nurse support the use of electroconvulsive therapy (ECT) as a first-line treatment?
- A. The client is in the first trimester of pregnancy.
- B. The client is gainfully employed.
- C. The client lives in an assisted living facility.
- D. The client is over 50 years of age.
Correct Answer: C
Rationale: ECT may be considered first-line for severe malignant catatonia in a controlled setting like an assisted living facility, where monitoring is feasible. Pregnancy and age are contraindications or require caution, and employment is irrelevant.
A client has experienced 48 hours of severe repeated bouts of vomiting. Which acid-base imbalance is of most concern?
- A. Respiratory acidosis
- B. Respiratory alkalosis
- C. Metabolic acidosis
- D. Metabolic alkalosis
Correct Answer: D
Rationale: Severe vomiting causes loss of gastric acid, leading to metabolic alkalosis (D). Respiratory imbalances (A, B) and metabolic acidosis (C) are less likely.
A client with AIDS tells the nurse that he regularly takes echinacea to boost his immune system. The nurse should tell the client that:
- A. Herbals can interfere with the action of antiviral medication
- B. Supplements have proven effective in prolonging life
- C. Herbals have been shown to decrease the viral load
- D. Supplements appear to prevent replication of the virus
Correct Answer: A
Rationale: Echinacea may interact with antiretroviral medications, potentially reducing their effectiveness.
A client with chest pain is scheduled for a heart catheterization. Which of the following would the nurse include in the client's care plan?
- A. Keep the client NPO for 12 hours after the procedure
- B. Inform the client that general anesthesia will be administered
- C. Assess the site for bleeding or hematoma once per shift
- D. Instruct the client that he might be asked to cough and breathe deeply during the procedure
Correct Answer: D
Rationale: During heart catheterization, the client may be asked to cough or breathe deeply to facilitate dye movement or assess respiratory response, a key part of preparation.