Nokea
The practical nurse assists in the care of a client who was admitted in a state of acute psychosis after ingesting recreational substances. The parents ask the nurse if the client will develop schizophrenia. Which response by the nurse is appropriate?
- A. I know it must be terrible to see your child like this, but your child will be fine within a few days.
- B. It is important to understand that most people have permanent adverse effects after an episode like this.
- C. We cannot predict whether your child will develop schizophrenia; close observation is required to determine the cause of psychosis.
- D. Your child would be fine right now if they had not taken these drugs. We will need to do some additional testing
Correct Answer: C
Rationale: Schizophrenia risk cannot be predicted from a single episode; observation is needed. Reassurance , permanent effects , and blame are inaccurate.
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The nurse is preparing to administer a scheduled dose of metoclopramide IV to a client with diabetic gastroparesis. Which clinical finding causes the nurse to question the prescription?
- A. Diarrhea
- B. Frequent burping
- C. Headache
- D. Sucking lip motions
Correct Answer: D
Rationale: Sucking lip motions suggest tardive dyskinesia, a contraindication for metoclopramide due to risk of worsening. Diarrhea , burping , and headache are not contraindications.
The client presents to the unit with complaints of shortness of breath. A tentative diagnosis of respiratory acidosis related to pneumonia is made. Which finding would support this diagnosis?
- A. $\mathrm{pH}$ of $7.45, \mathrm{CO}_2$ of $45, \mathrm{HCO}_3$ of 26
- B. $\mathrm{pH}$ of $7.35, \mathrm{CO}_2$ of $46, \mathrm{HCO}_3$ of 27
- C. $\mathrm{pH}$ of $7.34, \mathrm{CO}_2$ of $30, \mathrm{HCO}_3$ of 22
- D. $\mathrm{pH}$ of $7.44, \mathrm{CO}_2$ of $32, \mathrm{HCO}_3$ of 25
Correct Answer: B
Rationale: Respiratory acidosis is characterized by a low pH (<7.35) and elevated CO₂ (>45 mmHg) due to impaired gas exchange, as in pneumonia. Option B (pH 7.35, CO₂ 46, HCO₃ 27) is closest to this profile, with slight compensation. Options A, C, and D show normal or alkalotic pH or low CO₂.
The nurse is observing a staff member caring for a client who had a vaginal birth 30 minutes ago. The client is having difficulty with breastfeeding and is requesting assistance. The nurse should intervene if the staff member is observed
- A. providing supplemental formula feedings until improved breastfeeding occurs
- B. checking the newborn's position and sucking behavior during breastfeeding
- C. demonstrating to the client how to express breastmilk using the hand
- D. providing information on recognizing newborn hunger cues
Correct Answer: A
Rationale: Supplemental formula may undermine breastfeeding efforts early on. Checking position , demonstrating expression , and teaching hunger cues support breastfeeding.
The nurse is preparing to administer scheduled vaccines to a 15-month-old client with Kawasaki disease. The client received IV immunoglobulin 2 months ago. Which of the following vaccines should be delayed? Select all that apply.
- A. Haemophilus influenzae type b
- B. Hepatitis B
- C. Measles, mumps, and rubella
- D. Pneumococcal conjugate
- E. Varicella
Correct Answer: C,E
Rationale: MMR and varicella are live vaccines, which should be delayed 11 months post-IVIG due to antibody interference. Hib , hepatitis B , and pneumococcal are not affected.
The nurse is caring for an adult who had a cerebrovascular accident. The nurse gives the client a washcloth and encourages the client to wash her face. The client looks at the washcloth as though she does not know what to do with it. The nurse knows that this indicates that the client has which of the following?
- A. Apraxia
- B. Aphasia
- C. Agnosia
- D. Dysarthria
Correct Answer: C
Rationale: Agnosia is the inability to recognize objects, like a washcloth, despite intact sensory function, common post-CVA, unlike apraxia (motor planning), aphasia (language), or dysarthria (speech articulation).