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Questions 158

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Question 1 of 5

A client with polycythemia vera is admitted with complaints of difficulty breathing and pleuritic pain. Which lab finding is expected in the client with polycythemia vera?

Correct Answer: A

Rationale: Polycythemia vera is characterized by excessive red blood cell production, leading to an increased red blood cell count, which can cause hyperviscosity and symptoms like dyspnea.

Question 2 of 5

Which of the following nursing actions is essential to prevent drug-resistant tuberculosis?

Correct Answer: D

Rationale: Noncompliance with prescribed antituberculosis drug regimen is the primary cause of drug-resistant organisms. Noncompliance permits the mutation of organisms.

Question 3 of 5

One week ago, a 21-year-old client with a diagnosis of bipolar disorder was started on lithium 300 mg po qid. A lithium level is ordered. The client's level is 1.3 mEq/L. The nurse recognizes that this level is considered to be:

Correct Answer: A

Rationale: This answer is correct. The therapeutic range is 1.0-1.5 mEq/L in the acute phase. Maintenance control levels are 0.6-1.2 mEq/L. (B,
C) This answer is incorrect. A level of 1.3 mEq/L is within therapeutic range. This answer is incorrect.
Toxic poisoning is usually at the 2.0 level or higher.

Question 4 of 5

The physician prescribes regular insulin, five units subcutaneous. Regular insulin begins to exert an effect:

Correct Answer: C

Rationale: Regular insulin (short-acting) has an onset of 30–60 minutes when given subcutaneously, peaking at 2–3 hours. This allows time for absorption and glucose-lowering effects.

Question 5 of 5

A 6-month-old infant has developmental delays. His weight falls below the 5th percentile when plotted on a growth chart. A diagnosis of failure to thrive is made. What behaviors might indicate the possibility of maternal deprivation?

Correct Answer: B

Rationale: Normal infant attachment behaviors include responding to touch and wanting to be held. Maternal deprivation behaviors include poor feeding, stiffening and refusal to eat, and inconsistencies in responsiveness. Attachment behavior includes maintaining eye contact. Maternal deprivation behaviors include displeasure with touch and physical contact.

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