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The emergency department nurse is providing care for a rape victim. Which action
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.
Encouraging the client to divulge all the details - 🧠ANSWER ✔✔Providing
nonjudgmental care.
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,The nurse is reviewing labs for a client who is taking clozapine, 25mg QD for
treatment 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.
Decrease clozapine to 12.5 mg QD, start levothyroxine sodium 50 mcg QD. -
🧠ANSWER ✔✔Discontinue clozapine.
Rationale
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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.
The visiting nurse is assessing a client with early-stage dementia who has recently
been 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.
The client arranges to have groceries delivered. - 🧠ANSWER ✔✔The client is
showering and getting dressed with minimal assistance.
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, A client with stage 2 Alzheimer's disease is being cared for at home by the spouse.
The 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.
Establishment of a predictable daily schedule. - 🧠ANSWER ✔✔Periodic times of
respite from caregiving.
Rationale
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STATEMENT. ALL RIGHTS RESERVED
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