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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A woman who comes in for prenatal care has a history of herpes with outbreaks that occur every six months to a year. She asks if this means she will have a cesarean delivery. How should the nurse respond?
- A. If you have active lesions when you go into labor, you will need a cesarean section.'
- B. Cesarean delivery is the only way to protect your baby from herpes.'
- C. Cesarean delivery is no longer recommended for persons with herpes.'
- D. Your obstetrician will decide at the time of delivery which is best for you.'
Correct Answer: A
Rationale: Active herpes lesions at labor necessitate a cesarean to prevent neonatal herpes transmission; otherwise, vaginal delivery may be possible.
The nurse is caring for a client at 15 weeks gestation who has hyperemesis gravidarum. Which of the following findings would be consistent with the condition?
- A. heart rate less than 60/min
- B. moderate to high urine ketones
- C. increased serum potassium level
- D. blood pressure greater than 140/90 mm Hg
Correct Answer: B
Rationale: Hyperemesis gravidarum causes severe vomiting, leading to ketosis (moderate to high urine ketones) from fat breakdown. Bradycardia, hyperkalemia, and hypertension are not typical; tachycardia and hypokalemia may occur.
The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse?
- A. Teach the parents how to perform cardiopulmonary resuscitation
- B. Recommend that the parents give in when he holds his breath to prevent anoxia
- C. Advise the parents to ignore breath holding because breathing will begin as a reflex
- D. Instruct the parents on how to reason with the child about possible harmful effects
Correct Answer: C
Rationale: Advise the parents to ignore breath holding because breathing will begin as a reflex. Breath-holding is benign and self-resolving in toddlers.
The nurse has reinforced teaching with a client who has anxiety and a new prescription for alprazolam. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. I can continue to take my prescribed muscle relaxant as needed.
- B. I can omit the medication on days when I do not feel anxious.
- C. I should eliminate aged cheese and processed meats from my diet.
- D. I will discontinue the medication and notify my health care provider if I become pregnant.
Correct Answer: D
Rationale: Alprazolam is a benzodiazepine, and its use during pregnancy can pose risks to the fetus. Discontinuing and notifying the provider is critical. Muscle relaxants may enhance sedation, skipping doses disrupts therapeutic levels, and dietary restrictions like avoiding tyramine are not required for alprazolam.
The nurse is reinforcing teaching for a client with atrial fibrillation who has a new prescription for warfarin. The nurse should instruct the client to avoid excess or inconsistent intake of which of the following foods? Select all that apply.
- A. red meat
- B. bananas
- C. broccoli
- D. spinach
- E. kale
Correct Answer: C,D,E
Rationale: Broccoli, spinach, and kale are high in vitamin K, which can antagonize warfarin's anticoagulant effect. Consistent intake is key, but excess can reduce effectiveness. Red meat and bananas have minimal vitamin K and don't significantly affect warfarin.