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Questions 149

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Question 1 of 5

A young woman is transferred to a psychiatric crisis unit with a diagnosis of a dissociative disorder. The nurse knows which of the following comments by the client is MOST indicative of this disorder?

Correct Answer: C

Rationale: Dissociative disorders involve a disruption in the normal integration of consciousness, memory, identity, or perception. The statement 'I feel like I'm watching myself from outside my body' is indicative of depersonalization, a common symptom of dissociative disorders. Option A is associated with PTSD, B suggests a physical issue, and D is characteristic of psychotic disorders.

Question 2 of 5

The nurse is discharging a client with asthma who has a prescription for zafirlukast (Accolate). Which comment by the client would indicate a need for further teaching?

Correct Answer: A

Rationale: Zafirlukast should be taken on an empty stomach for better absorption. The other statements are correct: flulike symptoms and liver monitoring are relevant, and zafirlukast is not a rescue medication.

Question 3 of 5

A child who ingested 18 500-mg acetaminophen tablets 30 minutes ago is seen in the ED. Which of these orders should the nurse do first?

Correct Answer: A

Rationale: Activated charcoal is the priority within 1 hour of acetaminophen overdose to reduce absorption, followed by acetylcysteine to prevent liver damage.

Question 4 of 5

The client who is admitted with thrombophlebitis has an order for heparin. The medication should be administered using a/an:

Correct Answer: B

Rationale: An infusion controller ensures precise heparin delivery, critical for maintaining therapeutic levels and preventing complications.

Question 5 of 5

A client is admitted with a diagnosis of pernicious anemia. Which of the following signs or symptoms would indicate that the client has been noncompliant with ordered B12 injections?

Correct Answer: C

Rationale: Pernicious anemia causes B12 deficiency, leading to neurological symptoms like paresthesia. Noncompliance with B12 injections would result in persistent or worsening paresthesia.

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