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A nurse is assessing a client who has bipolar disorder and is experiencing a depressive episode.
Which finding should the nurse expect?
- A. Move quickly from one idea to the next
- B. Feelings of hopelessness or worthlessness
- C. Decreased energy and fatigue
- D. Difficulty concentrating or making decisions
- E. Changes in appetite, either increased or decreased
Correct Answer: B
Rationale: The correct answer is B: Feelings of hopelessness or worthlessness. This is a key symptom of depression and is often present in individuals experiencing a depressive episode. It is important for the nurse to recognize this as it can indicate a serious mental health issue that requires intervention. Choices A, C, D, and E are also common symptoms of depression, but they are not as specific to the core of the condition as feelings of hopelessness or worthlessness. Moving quickly from one idea to the next (A) may suggest mania or hypomania rather than depression. Decreased energy and fatigue (C), difficulty concentrating or making decisions (D), and changes in appetite (E) are also common in depression, but they are not as indicative of the deep emotional distress associated with feelings of hopelessness or worthlessness.
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A nurse is assessing a client who received hydromorphone 4mg IV 15 min ago. The client has a respiratory rate of 10/min. the nurse should prepare to administer which of the following medications?
- A. Naloxone
- B. Flumazenil
- C. Activated charcoal
- D. Atropine
- E. Diphenhydramine
Correct Answer: A
Rationale: The correct answer is A: Naloxone. Hydromorphone is an opioid that can cause respiratory depression. The client's low respiratory rate of 10/min indicates potential opioid overdose. Naloxone is an opioid antagonist that reverses the effects of opioids, such as respiratory depression. Administering naloxone can help restore normal breathing in the client. Flumazenil (B) is used to reverse the effects of benzodiazepines, not opioids. Activated charcoal (C) is used for toxin ingestion, not opioid overdose. Atropine (D) is a medication used for bradycardia, not respiratory depression. Diphenhydramine (E) is an antihistamine and is not indicated in this situation.
A nurse is planning teaching for a client who has a newly implanted implantable cardioverter/defibrillator.
Which of the following information should the nurse include?
- A. Return in two weeks for a follow up MRI - MRI should be avoided
- B. Expect to have a rapid pulse rate for the first few weeks?
- C. Resume tub baths and swimming after 24hr
- D. Wear loose fitting clothing
Correct Answer: D
Rationale: The correct answer, D, "Wear loose fitting clothing," is important post-surgery to prevent constriction on the surgical site and promote healing. Tight clothing can lead to increased pain and delayed recovery. Choice A is incorrect as MRI should be avoided post-surgery due to potential interference with healing. Choice B is incorrect as a rapid pulse rate is not a typical expectation post-surgery. Choice C is incorrect as tub baths and swimming should be avoided to prevent infection.
A nurse is planning care for a client who sustained a major burn over 20% of the body.
Which of the following interventions should the nurse include to support the client's nutritional requirements?
- A. Keep a calorie count for foods and beverages
- B. Provide a high-calorie, high-protein diet
- C. Encourage a low-fat diet to prevent digestive issues
- D. Restrict oral intake and provide IV fluids only
Correct Answer: B
Rationale: The correct answer is B: Provide a high-calorie, high-protein diet. This intervention supports the client's nutritional requirements by ensuring they receive adequate energy and protein for healing and overall health. High-calorie intake can prevent malnutrition, while high-protein intake supports tissue repair and immune function. Keeping a calorie count (A) is helpful but not as crucial as ensuring the client receives enough calories and protein. Encouraging a low-fat diet (C) is not the priority when aiming to meet nutritional requirements. Restricting oral intake (D) and providing IV fluids only can lead to malnutrition and should be avoided.
Admission Assessment
Client reports new onset of fever and discomfort in their joints and increase malaise. No relevant
medical history. Client is alert to person, place, time, and situation. Reports generalized pain as 4
on a scale of 0 to 10. Macular rash present on cheeks bilateral. Lungs clear anterior and posterior.
Bowel sounds active in all 4 quadrants. Last bowel movement 1 day ago. Skin warm, dry, and
intact. Capillary refill less than 3 seconds. A 20-gauge IV saline lock inserted in back left hand
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing.
- A. Ensure that client has intake of at least 200mL/hr
- B. Initiate contact precautions
- C. Prepare client for light therapy
- D. Sickle cell crisis
- E. Psoriasis
- F. Osteomyelitis
Correct Answer: B,C
Rationale: Increased fluid intake and contact precautions are essential for managing systemic lupus erythematosus.
A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?
- A. Dyspnea
- B. Pain at the surgical site
- C. Mild nausea
- D. Temperature of 37.5°C (99.5°F)
Correct Answer: A
Rationale: The correct answer is A: Dyspnea. Dyspnea in a postoperative client with a history of pulmonary embolism indicates a potential complication, such as a recurrent or new pulmonary embolism, which can be life-threatening. The nurse should report this finding to the provider immediately for further evaluation and intervention to prevent worsening respiratory distress and potential respiratory failure. Pain at the surgical site (choice B) is expected postoperatively and can be managed with appropriate pain medications. Mild nausea (choice C) is a common postoperative symptom and can be managed with antiemetic medications. A temperature of 37.5°C (99.5°F) (choice D) may indicate a mild fever, which can be monitored unless accompanied by other concerning symptoms.