Nokea
The nurse is reviewing the medical record for an adolescent client with major depressive disorder. Which of the following findings would be consistent with the condition? Select all that apply.
- A. often sleeps during class or after-school activities
- B. has received disciplinary action at school due to absenteeism and angry outbursts
- C. has unintentionally lost 8 lb (3.6 kg) over the past 3 weeks
- D. abruptly quit playing sports despite receiving previous athletic awards and trophies
- E. voices concern about the appearance of acne on the face
Correct Answer: A,B,C,D
Rationale: Excessive sleep, irritability (outbursts), weight loss, and loss of interest in activities (quitting sports) are hallmarks of depression. Acne concern is typical adolescent behavior, not specific to depression.
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The nurse is caring for a client who has a prescription for insulin lispro 1 unit subcutaneously per 15 g of carbohydrates with each meal. The client's meal contains 75 g of carbohydrates. How many units of insulin lispro should the nurse administer to the client? Record your answer using a whole number.
Correct Answer: 5
Rationale: 75 g carbohydrates ÷ 15 g/unit = 5 units of insulin lispro.
The nurse is caring for a client who just had a total thyroidectomy. Which finding does the nurse recognize as most important to report immediately?
- A. Elevated blood pressure
- B. Heart rate irregularity
- C. Low oxygen saturation
- D. Noisy breathing
Correct Answer: D
Rationale: Noisy breathing post-thyroidectomy may indicate airway obstruction from hematoma or edema, a life-threatening emergency. Other findings are less immediately critical but still require monitoring.
The nurse is collecting data on a 2-day-old infant with suspected Hirschsprung disease. Which findings should the nurse anticipate? Select all that apply.
- A. Bright red bleeding from anus
- B. Distended abdomen
- C. Has not passed stool (meconium)
- D. Nonbilious vomiting
- E. Refuses to feed
Correct Answer: B,C,D
Rationale: Hirschsprung disease causes intestinal obstruction, leading to a distended abdomen, failure to pass meconium, and nonbilious vomiting. Bright red bleeding suggests other causes (e.g., fissure). Feeding refusal is less specific.
The nurse's neighbor has a total cholesterol of 450 mg/dL. The neighbor asks the nurse what this means. What should the nurse include when responding?
- A. The cholesterol level is slightly high, but exercise and a low-fat diet should reduce it to normal.
- B. The cholesterol level is below normal levels, but this is good.
- C. The cholesterol level is high. The neighbor should talk with the physician about ways to lower it.
- D. The cholesterol is within normal limits.
Correct Answer: C
Rationale: A cholesterol level of 450 mg/dL is significantly elevated, increasing cardiovascular risk, requiring medical consultation.
An older adult is diagnosed with open-angle glaucoma. Which comment by the client indicates understanding of the management of the condition?
- A. I will take the eye drops every day.'
- B. I hope the medicine works and I am cured soon.'
- C. My wife is worried that I may give her glaucoma.'
- D. How long will it be before I need surgery?'
Correct Answer: A
Rationale: Daily eye drops control intraocular pressure in open-angle glaucoma, a chronic condition, indicating understanding, unlike expecting a cure, contagiousness, or immediate surgery.