Nokea
When assessing a client for possible disordered water balance, the nurse checks the client?s urine specific gravity. Which result would lead the nurse to suspect that the client is experiencing severe disordered water balance?
- A. 1.02
- B. 1.011
- C. 1.005
- D. 1.002
Correct Answer: D
Rationale: A urine specific gravity of 1.002 (D) is extremely low, indicating overly dilute urine, consistent with severe disordered water balance (e.g., psychogenic polydipsia). Normal range is 1.010?1.030, so 1.020 (A) and 1.011 (B) are closer to normal, and 1.005 (C) is less severe.
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The nurse is assessing a newly admitted client diagnosed with schizoaffective disorder. The nurse assesses the client?s level of anxiety and reactions to stressful situations, obtaining this information for which reason?
- A. To help determine the client?s outcomes after treatment
- B. To help identify whether or not the client?s mental competency is intact
- C. To act as a predictor of the client?s risk for a suicide attempt
- D. To provide a basis for evaluating the client?s social skills
Correct Answer: C
Rationale: Assessing anxiety and stress reactions (C) in schizoaffective disorder helps predict suicide risk, as heightened anxiety can exacerbate mood and psychotic symptoms. Outcomes (A), competency (B), and social skills (D) are less directly tied to this assessment.
The nurse is caring for a client who was diagnosed with schizoaffective disorder. Based on the nurse?s understanding of this disorder, the nurse develops a plan of care to address which issue as the top priority?
- A. Suicide
- B. Aggression
- C. Substance abuse
- D. Eating disorder
Correct Answer: A
Rationale: Suicide (A) is the top priority in schizoaffective disorder due to the combined risk of mood disturbances (e.g., depression) and psychosis, both of which elevate suicide risk. Aggression (B), substance abuse (C), and eating disorders (D) are concerns but less immediate unless actively present.
A client hospitalized for treatment of schizophrenia has been receiving olanzapine (Zyprexa) for the past 2 months. The nurse would be especially alert for which of the following?
- A. Weight loss
- B. Hypertension
- C. Diarrhea
- D. Diabetes
Correct Answer: D
Rationale: Olanzapine (D) is associated with metabolic side effects, including an increased risk of diabetes due to weight gain and insulin resistance. Weight loss (A) is unlikely, hypertension (B) is less common, and diarrhea (C) is not a primary concern with olanzapine.
While caring for a hospitalized client with schizophrenia, the nurse observes that the client is listening to the radio. The client tells the nurse that the radio commentator is speaking directly to him. The nurse interprets this finding as which of the following?
- A. Autistic thinking
- B. Concrete thinking
- C. Referential thinking
- D. Illusional thinking
Correct Answer: C
Rationale: Referential thinking (C) describes the client?s belief that neutral events, like a radio broadcast, are personally directed at them, a common delusion in schizophrenia. Autistic thinking (A) involves private, illogical thoughts, concrete thinking (B) is overly literal interpretation, and illusional thinking (D) is not a standard term, making them incorrect.
The nurse is caring for a client who was just admitted with a diagnosis of schizoaffective disorder with depression. Which agent would the nurse anticipate as being prescribed for this client?
- A. Lithium
- B. Haloperidol
- C. Chlorpromazine
- D. Clozapine
Correct Answer: D
Rationale: Clozapine (D) is effective for schizoaffective disorder, addressing both psychotic and mood symptoms, especially in treatment-resistant cases. Lithium (A) is primarily for bipolar disorder, and haloperidol (B) and chlorpromazine (C) are less effective for mood components.