Nokea
The nurse is working with a client in the psychiatric unit. The client has memory gaps, which she fills in with detailed fantasies that she believes to be true. The nurse understands that the client is exhibiting which type of abnormal thought process?
- A. Delusion
- B. Confabulation
- C. Tangentiality
- D. Flight of ideas
Correct Answer: B
Rationale: Confabulation involves filling memory gaps with fabricated details believed to be true, common in certain psychiatric or neurological conditions.
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The client with color blindness will most likely have problems distinguishing which of the following colors?
- A. Orange
- B. Violet
- C. Red
- D. White
Correct Answer: C
Rationale: Red-green color blindness is the most common type, making it difficult to distinguish red.
Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning?
- A. A 6-month-old
- B. A 4-year-old
- C. A 12-year-old
- D. A 13-year-old
Correct Answer: B
Rationale: A 4-year-old is at greatest risk due to their curiosity, mobility, and tendency to explore their environment, often putting objects in their mouths.
Six hours after birth, the infant is found to have an area of swelling over the right parietal area that does not cross the suture line. The nurse should chart this finding as:
- A. A cephalhematoma
- B. Molding
- C. Subdural hematoma
- D. Caput succedaneum
Correct Answer: A
Rationale: A cephalhematoma is a subperiosteal hemorrhage that does not cross suture lines, commonly seen in newborns.
A client is prescribed heparin 2,000 units SC q8 hours. The pharmacy sends heparin 5,000 units/mL. How many mL should the nurse administer every 24 hours?
- A. 0.4 mL/day
- B. 0.8 mL/day
- C. 1.2 mL/day
- D. 1.4 mL/day
Correct Answer: C
Rationale: Dose per injection: 2,000 units ÷ 5,000 units/mL = 0.4 mL. Q8 hours = 3 doses/day. 0.4 mL × 3 = 1.2 mL/day.
The physician has ordered Claforan (cefotaxime) 1 g every 6 hours. The pharmacy sends the medication premixed in 100 mL of D5W with instructions to infuse the medication over 1 hour. The IV set delivers 20 drops per milliliter. The nurse should set the IV rate at:
- A. 50 drops per minute
- B. 33 drops per minute
- C. 25 drops per minute
- D. 12 drops per nursing diagnosis.
- E. 33 drops per minute
- F. The IV rate is calculated as: 100 mL over 60 minutes with 20 drops/mL = (100 × 20) ÷ 60 = 33.33 drops/min, rounded to 33 drops/min.
Correct Answer:
Rationale: