Nokea
The nurse on the mental health unit is caring for assigned clients. The nurse should first check the client with
- A. obsessive-compulsive disorder who has spent the past hour counting socks
- B. major depressive disorder who has consumed no food from the past 2 meal trays
- C. posttraumatic stress disorder who reports a depressed mood and feelings of hopelessness
- D. bipolar I disorder who is experiencing an acute manic episode and reports sleeping 4 hours last night
Correct Answer: C
Rationale: Hopelessness and depressed mood in PTSD indicate suicide risk, requiring immediate assessment. OCD behavior , poor intake , and mania are less urgent but still need attention.
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An adult who has a tracheostomy needs to be suctioned. How should the nurse position the client for this procedure?
- A. Supine
- B. Semi-sitting
- C. Left lateral
- D. Semi-lateral
Correct Answer: B
Rationale: Semi-sitting facilitates airway access and reduces aspiration risk during tracheostomy suctioning. Supine or lateral positions are less effective.
A client diagnosed with metastatic cancer of the bone is exhibiting mental confusion and a BP of 160/100. Which laboratory value would correlate with the client's symptoms reflecting a common complication with this diagnosis?
- A. Potassium 5.2 mEq/l
- B. Calcium 13 mg/dl
- C. Inorganic phosphorus 1.7 mEq/l
- D. Sodium 138 mEq/l
Correct Answer: B
Rationale: Hypercalcemia is a common occurrence with cancer of the bone. The potassium level is elevated but does not relate to the diagnosis, so answer A is incorrect. Answers C and D are both normal levels, so they are incorrect.
A 3-month-old infant is treated in the emergency department for a spiral femur fracture. The parent reports that the infant sustained the injury after rolling off the bed. What is the priority nursing action?
- A. Document a description of the injury
- B. Question the parent about where the infant sleeps
- C. Report the injury per facility protocol
- D. Separate the parent from the infant
Correct Answer: C
Rationale: A spiral fracture in a non-mobile infant is inconsistent with rolling off a bed, suggesting abuse. Reporting is the priority to ensure safety. Documentation , questioning , and separation follow.
The nurse is talking with the parents of a 2 year old client about nutritional choices to promote growth and development. The family observes a strict vegan diet. Which of the following information should the nurse include? Select all that apply.
- A. Diets consisting of legumes as the only protein source are sufficient for growth.
- B. Green, leafy vegetables such as cabbage and broccoli are good sources of calcium.
- C. Preparing meals with vegetables and fruits will ensure sufficient vitamin B12 intake
- D. Sunlight, mushrooms, and fortified,subscribe plant based milks are good sources of vitamin D.
- E. Try to consume foods high in iron with foods high in vitamin C to increase iron absorption.
Correct Answer: B,D,E
Rationale: Leafy greens provide calcium, sunlight/mushrooms/fortified milks supply vitamin D, and vitamin C with iron enhances absorption. Legumes alone lack essential amino acids, and vegetables/fruits don't provide B12.
The nurse is caring for a client with a long leg cast. During discharge teaching about appropriate exercises for the affected extremity, the nurse should recommend exercises
- A. Isometric
- B. Range of motion
- C. Aerobic
- D. Isotonic
Correct Answer: A
Rationale: Isometric. The nurse should instruct the client on isometric exercises for the muscles of the casted extremity, i.e., instruct the client to alternately contract and relax muscles without moving the affected part.