Nokea
Which of the following findings indicate a positive test?
- A. An induration measuring 10 mm
- B. A reddened area with no induration
- C. An induration measuring 3 mm
- D. A blister at the injection site
Correct Answer: A
Rationale: The correct answer is A because an induration measuring 10 mm is considered positive for a tuberculin skin test, indicating exposure to tuberculosis. A larger induration size suggests a stronger immune response. Choice B, a reddened area with no induration, is not specific for a positive test. Choice C, an induration measuring 3 mm, is below the threshold for positivity. Choice D, a blister at the injection site, is a sign of irritation rather than a positive test result.
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Which of the following statements should the nurse include in the hand-off report?
- A. The estimated blood loss was 250 mL.
- B. The client has a good appetite and ate well before surgery.
- C. The client's family visited during the recovery period.
- D. The client's call light is within reach.
Correct Answer: A
Rationale: The correct answer is A: The estimated blood loss was 250 mL. This statement is important for the receiving nurse to know as it provides crucial information about the client's condition post-surgery. It helps in monitoring for signs of hemorrhage or other complications. The other choices (B, C, D) are not essential for the hand-off report as they do not directly impact the client's immediate care or safety. Choice B is subjective and not a clinical observation. Choice C is about the client's family, which is not pertinent to the client's medical status. Choice D is a general safety measure and not specific to the client's condition.
Fill in the blanks with one condition and one client finding.The client is most likely experiencing---------- as evidenced by the client's--------
- A. Mania
- B. Delirium
- C. Catatonia
- D. Magical thinking
- E. Euphoric mood
- F. Hypervigilance
- G. Panic disorder
Correct Answer: A,E
Rationale: The correct answer is A, E. Mania is characterized by elevated mood, increased energy levels, and impulsivity. The client is most likely experiencing mania as evidenced by euphoric mood. Euphoric mood is a key symptom of mania, reflecting a heightened sense of well-being and happiness. Therefore, the combination of mania and euphoric mood is indicative of a manic episode. Choices B, C, D, F, and G are incorrect as they do not align with the symptoms and presentation of mania. Delirium is characterized by confusion and disorientation, not euphoric mood. Catatonia involves motor disturbances, not euphoric mood. Magical thinking refers to unrealistic beliefs, not necessarily elevated mood. Hypervigilance is associated with anxiety disorders, not mania. Panic disorder is characterized by recurrent panic attacks, not euphoric mood.
Which of the following medications should the nurse identify as being incompatible with warfarin?
- A. Naproxen
- B. Metformin
- C. Lisinopril
- D. Albuterol
Correct Answer: A
Rationale: The correct answer is A: Naproxen. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can increase the risk of bleeding when taken with warfarin, an anticoagulant. This is due to their combined effects on blood clotting. Metformin, Lisinopril, and Albuterol do not have a significant interaction with warfarin in terms of bleeding risk. Therefore, the nurse should identify Naproxen as incompatible with warfarin to prevent potential adverse effects.
The nurse should identify the cardiac rhythm as which of the following?
- A. Ventricular asystole
- B. Second-degree heart block
- C. Sinus Tachycard
- D. Atrial fibrillation
Correct Answer: D
Rationale: The correct answer is D: Atrial fibrillation. In atrial fibrillation, the atria quiver instead of contracting effectively, leading to an irregular and rapid heart rate. This can be identified on an ECG by the absence of distinct P waves and irregular R-R intervals. Ventricular asystole (A) is the absence of ventricular contractions, second-degree heart block (B) is characterized by intermittent conduction block between the atria and ventricles, and sinus tachycardia (C) is a regular rapid heart rate originating from the sinus node.
The nurse should expect the adolescent to be in which of the following of erikson stages of psychosocial development.
- A. Identity versus role confusion
- B. Autonomy versus shame and doubt
- C. Initiative versus guilt
- D. Intimacy versus isolation
Correct Answer: A
Rationale: The correct answer is A: Identity versus role confusion. During adolescence, individuals are in Erikson's stage of developing a sense of identity and may struggle with role confusion. This stage typically occurs during the teenage years, where adolescents are exploring their personal values, beliefs, and goals. They are trying to establish a sense of self and may question their identity and place in the world. Choices B, C, and D are incorrect because Autonomy versus shame and doubt relates to toddlers, Initiative versus guilt relates to preschoolers, and Intimacy versus isolation relates to young adults. This makes A the most appropriate choice for an adolescent's stage of psychosocial development.