Nokea
Which finding for a patient with an eating disorder most clearly indicates the need for hospitalization?
- A. Weight 15% below ideal weight
- B. Urine output less than 30 mL/hr
- C. Serum potassium 3.4 mEq/L
- D. Pulse rate 54 beats/min
Correct Answer: B
Rationale: The correct answer is B because urine output less than 30 mL/hr indicates severe dehydration and compromised kidney function, which can lead to organ failure. Hospitalization is necessary for immediate fluid resuscitation and monitoring. Option A is indicative of malnutrition but does not directly signify acute medical complications. Option C suggests hypokalemia, which can be managed on an outpatient basis. Option D, a low pulse rate, may be a sign of bradycardia but typically does not require immediate hospitalization unless accompanied by other severe symptoms.
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The management of nausea as a side effect of lithium carbonate (Eskalith) includes instructing the patient to take the medication:
- A. after meals
- B. between meals
- C. with a carbonated beverage
- D. with a large glass of water
Correct Answer: A
Rationale: Taking lithium after meals reduces gastrointestinal irritation, including nausea, by buffering its absorption.
A nurse can anticipate anticholinergic side effects are likely when a patient takes:
- A. Lithium (Lithobid).
- B. Buspirone (BuSpar).
- C. Risperidone (Risperdal).
- D. Fluphenazine (Prolixin)
Correct Answer: D
Rationale: The correct answer is D, Fluphenazine (Prolixin), as it is a typical antipsychotic medication known to have strong anticholinergic effects. Anticholinergic side effects include dry mouth, constipation, blurred vision, and urinary retention. Fluphenazine blocks the action of acetylcholine in the brain, leading to these side effects. Choices A, B, and C are incorrect as they do not have significant anticholinergic effects compared to Fluphenazine. Lithium is a mood stabilizer, Buspirone is an anxiolytic, and Risperidone is an atypical antipsychotic, none of which are known for causing prominent anticholinergic side effects.
The wife of a client newly diagnosed with paranoid schizophrenia asks the nurse, 'My husband was well adjusted until a month ago, and then, after a lot of work stress, he got sick. What can I expect? Will he be this sick for the rest of his life?' What information can the nurse provide about prognosis?
- A. This disorder responds well to treatment and, with follow-up, may not recur.'
- B. All types of schizophrenia are chronic relapsing disorders.'
- C. Outcomes are poor related to client prehospital disorganization.'
- D. The usual outcome is that only partial remission is achieved.'
Correct Answer: A
Rationale: Step 1: Paranoid schizophrenia is a subtype that tends to have a better prognosis compared to other types.
Step 2: The statement that the disorder responds well to treatment and may not recur aligns with the typical course of paranoid schizophrenia.
Step 3: With proper medication and therapy, individuals with paranoid schizophrenia can experience significant improvement and have periods of stability.
Step 4: Recurrence of symptoms is less likely compared to other types of schizophrenia.
Step 5: Therefore, choice A is correct as it provides accurate information about the prognosis of paranoid schizophrenia.
Summary: Choice B is incorrect because not all types of schizophrenia are chronic relapsing disorders. Choice C is incorrect as outcomes are not solely determined by prehospital disorganization. Choice D is incorrect as partial remission is not the usual outcome for paranoid schizophrenia.
A woman has been severely beaten by her husband, has no relatives or friends in the community, is afraid to return home, has no financial resources of her own, and has no job skills. Which would be the most important referral for the nurse to make?
- A. Community food cupboard
- B. Vocational counseling
- C. Law enforcement
- D. Safe house or shelter
Correct Answer: D
Rationale: The correct answer is D: Safe house or shelter. This option is the most important referral because the woman is in immediate danger and needs a safe place to stay away from her abusive husband. It prioritizes her safety and well-being. Referring her to a safe house can provide her with protection, resources, and support to help her escape the abusive situation.
Choice A (Community food cupboard) is incorrect as it does not address the woman's immediate safety needs. Choice B (Vocational counseling) is also not the most urgent referral in this situation as the woman's safety should be the priority. Choice C (Law enforcement) might be necessary in the long run, but the immediate concern is ensuring the woman's safety by referring her to a safe house or shelter.
According to statistical research data, which of these children currently being followed by the pediatric nurse practitioner is at the greatest risk for fatal abuse?
- A. A child who is 2 years old and has cerebral palsy
- B. A child who is 5 years old and has measles
- C. A child who is 8 years old and has appendicitis
- D. A child who is 11 years old and has a fractured humerus
Correct Answer: A
Rationale: The correct answer is A because young children with disabilities, like cerebral palsy, are at the highest risk for fatal abuse based on statistical research. These children may be more vulnerable due to their dependency on caregivers and communication challenges. Choice B is incorrect as measles, although serious, is not associated with fatal abuse. Choice C is incorrect as appendicitis is a medical condition and not a risk factor for abuse. Choice D is incorrect as a fractured humerus, while concerning, does not indicate a higher risk for fatal abuse compared to a child with cerebral palsy.