Nokea
While conducting a mental status examination of a newly admitted male client, the PN notes that his head is lowered, and he shows no emotion or expression when speaking. Based on these observations, what documentation should the PN include?
- A. Impaired verbalization
- B. Depressed mood
- C. Flat affect
- D. Diminished LOC
Correct Answer: C
Rationale: The correct answer is C: 'Flat affect.' Flat affect refers to a lack of emotional expression, which the PN observed in the client. This observation is significant as it can provide valuable information for the client's mental health assessment and subsequent care planning. Choice A, 'Impaired verbalization,' does not capture the lack of emotional expression seen in the client. Choice B, 'Depressed mood,' may not accurately reflect the observed behavior of the client. Choice D, 'Diminished LOC,' pertains to the level of consciousness, which was not indicated as being a concern in the scenario provided.
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Before administering a scheduled dose of insulin to a 10-year-old child who is learning diabetic self-care, which information is most important for the PN to ask the child?
- A. How much exercise did the child have today?
- B. Did the child perform a finger stick?
- C. When did the child last urinate?
- D. Has the child eaten recently?
Correct Answer: B
Rationale: The correct answer is B: 'Did the child perform a finger stick?' Before administering insulin, it is crucial to check the child's blood glucose level to prevent hypoglycemia. Performing a finger stick blood glucose test provides essential information on the current blood sugar level. Choice A ('How much exercise did the child have today?') is not as critical as monitoring blood glucose levels directly. Choice C ('When did the child last urinate?') is not directly related to the immediate need for insulin administration. Choice D ('Has the child eaten recently?') is important but not as crucial as knowing the current blood glucose level.
During a blood transfusion, which sign or symptom should prompt the healthcare provider to immediately stop the transfusion?
- A. Slight increase in blood pressure
- B. Elevated temperature and chills
- C. Mild nausea
- D. Slight headache
Correct Answer: B
Rationale: The correct answer is B: Elevated temperature and chills. These symptoms are indicative of a transfusion reaction, which can be severe and life-threatening. It is crucial to stop the transfusion immediately and notify the healthcare provider for further assessment and management. Elevated temperature and chills are classic signs of a transfusion reaction, specifically indicating a possible febrile non-hemolytic reaction. Choice A, a slight increase in blood pressure, is not typically a reason to stop a transfusion unless it is a significant sudden increase. Mild nausea (Choice C) and a slight headache (Choice D) are common side effects of blood transfusions and are not primary indicators of a transfusion reaction that require immediate cessation of the transfusion.
Patients are coming into the emergency room as a result of an apartment house fire. You are examining a patient who is in distress but has no visible burn marks. You suspect that she is suffering from inhalation burns. Which of the following signs would NOT be associated with inhalation burns?
- A. Singed nasal hairs
- B. Conjunctivitis
- C. Hoarseness
- D. Clear sputum
Correct Answer: D
Rationale: Clear sputum would not be associated with inhalation burns. Inhalation burns typically present with symptoms like singed nasal hairs, conjunctivitis, hoarseness, and possibly soot in sputum due to smoke inhalation. Clear sputum suggests that there is no significant inflammation or injury to the respiratory tract, which is not consistent with the typical findings in inhalation burns. The other choices are associated with inhalation burns: singed nasal hairs can occur due to exposure to hot air or gases, conjunctivitis can result from irritating substances in smoke, and hoarseness can be due to airway irritation.
Which of the following is a priority for the nurse to include in the teaching of a client who was recently prescribed alprazolam (Xanax) as an oral medication?
- A. Monitor heart rate before taking the medication
- B. Monitor temperature daily
- C. Avoid unprotected exposure to sunlight
- D. Avoid alcohol
Correct Answer: D
Rationale: The correct answer is D: 'Avoid alcohol.' Alprazolam (Xanax) can have central nervous system depressant effects, which are exacerbated by alcohol. It is crucial to avoid alcohol while taking this medication to prevent severe sedation and respiratory depression. Monitoring heart rate (choice A) is not directly related to alprazolam administration. Monitoring temperature daily (choice B) is not a priority teaching point for a client prescribed alprazolam. Avoiding unprotected exposure to sunlight (choice C) is not specifically linked to the use of alprazolam.
Which of the following dietary modifications should be recommended for a patient with chronic kidney disease (CKD)?
- A. High protein, low sodium
- B. Low protein, high potassium
- C. Low sodium, low potassium
- D. High calcium, low phosphorus
Correct Answer: C
Rationale: A low sodium, low potassium diet is often recommended for patients with CKD to manage fluid balance and prevent electrolyte imbalances that the kidneys can no longer regulate effectively. High protein diets, as mentioned in choice A, can put extra strain on the kidneys, making it an incorrect choice. Choice B, which suggests a low protein, high potassium diet, is also incorrect because high potassium levels can be harmful to individuals with CKD. Choice D, advocating for a high calcium, low phosphorus diet, is not the typical dietary recommendation for CKD patients, even though managing calcium and phosphorus levels is important in their diet.