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NEW EXAM WITH Q&A UPDATED
ANSWERS 100% GUARANTEED A+
he emergency department nurse is providing care for a rape victim. Which action
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represents an essential element of care for this client?
Providing nonjudgmental care.
Conveying outrage that this occurred.
Sympathizing with the client's sense of shame.
ncouraging the client to divulge all the details - CORRECT ANSWER-Providing
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nonjudgmental care.
he nurse is reviewing labs for a client who is taking clozapine, 25mg QD for treatment
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of disorganized schizophrenia. The labs are documented as follows: RBC 4.5
million/mcL, WBC 1000/mcL, TSH 1.2 mc-IU. Based on these results, which order
should the nurse anticipate the health care provider to write?
Discontinue clozapine.
Administer levothyroxine sodium 25 mcg QD.
Administer ferrous sulfate 100mg QD.
ecrease clozapine to 12.5 mg QD, start levothyroxine sodium 50 mcg QD. -
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CORRECT ANSWER-Discontinue clozapine.
ationale
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Agranulocytosis is an adverse side effect of clozapine that can cause lethal infections.
Based on the client's results, clozapine should be discontinued; the thyroid and RBC
results are normal and do not need to be treated.
, he visiting nurse is assessing a client with early-stage dementia who has recently been
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prescribed donepezil (Aricept). Which information obtained from the client's family
member demonstrates that the medication is effective?
The client is showering and getting dressed with minimal assistance.
The client uses confabulation to cover up memory loss.
The client did not attend the family reunion last weekend.
he client arranges to have groceries delivered. - CORRECT ANSWER-The client is
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showering and getting dressed with minimal assistance.
client with stage 2 Alzheimer's disease is being cared for at home by the spouse. The
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client's spouse tells the nurse about the emotional difficulties involved in providing
fulltime care at home. Which self-care activity is most important for the nurse to
recommend to the spouse?
Periodic times of respite from caregiving.
Regular attendance at church services.
Participation in reminiscence therapy.
stablishment of a predictable daily schedule. - CORRECT ANSWER-Periodic times of
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respite from caregiving.
ationale
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Caregiver role strain may be attributed to many different factors. The nurse must
become familiar with this diagnosis in order to accurately assess the caregiver and offer
effective interventions. One important recommendation is to have the caregiver
incorporate periodic breaks as part of the daily routine to relieve stress. The nurse
should contact the client's manager and provide the client's caregiver a list of agencies
offering "Respite Care".
client with delirium keeps attempting to get out of bed and has fallen twice, despite
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being under close-observation. The charge nurse calls the health care provider to obtain
, n order for mechanical restraints. Which statement is correct regarding the mechanical
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restraint policy?
he client will need to remain on close-observation with a documentation note every 15
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minutes.
The client no longer require close-observation, but must be checked at regular intervals.
The client may be sedated and left alone as long as the restraints remain in place.
estraints may be applied based on verbal orders received over the phone. -
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CORRECT ANSWER-The client will need to remain on close-observation with a
documentation note every 15 minutes.
client with long-term alcohol addiction is admitted to the emergency department.
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Which medications should the nurse anticipate the healthcare provider will prescribe for
this client?
Diazepam.
Methadone.
Multivitamins.
Thiamine (vitamin B1).
Monoamine oxidase inhibitors. - CORRECT ANSWER-Diazepam.
Multivitamins.
Thiamine (vitamin B1).
he nurse is caring for a victim of severe emotional violence inflicted by her husband.
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The client states that the abuse occurs most often when her husband is intoxicated, and
that he is always remorseful afterwards. She also tells the nurse that her husband's
father was an alcoholic who beat him and his mother. What evidence exists that the
husband is at risk of becoming a perpetrator of physical abuse?
, Past childhood abuse.
Feelings of remorse.
Temporary behavioral changes.
Excessive alcohol consumption. - CORRECT ANSWER-Past childhood abuse.
he nurse is interviewing a newly admitted client with major depression. Which
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statement by the client is evidence of a genetic etiology of this mood disorder?
My mother was diagnosed with bipolar affective disorder.
My uncle was diagnosed with schizophrenia.
My cousin was hospitalized with suicidal ideation last year.
y niece is being evaluated for borderline personality disorder. - CORRECT
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ANSWER-My mother was diagnosed with bipolar affective disorder.
hat are some of the family risk factors the nurse should look for when interviewing a
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client who is suspected of being in an abusive relationship?
Mental health problems in the nuclear family..
Substance abuse by household members.
Family relationships that appear dysfunctional.
The ethnic and cultural background of the family.
ducational background of client and family members. - CORRECT ANSWER-Mental
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health problems in the nuclear family..
Substance abuse by household members.
Family relationships that appear dysfunctional.