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NCLEX-RN

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Question 1 of 5

During the admitting mental health assessment, a client demonstrates involuntary muscular activity. He has a marked facial tic around the mouth that is distracting to the nurse during the interview. The nurse recognizes the behavior and documents it as:

Correct Answer: A

Rationale: The client is demonstrating dyskinesia, which is involuntary muscular activity, such as tic, spasm, or myoclonus. Akathisia is regular rhythmic movements usually of the lower limbs, such as constant motor restlessness. Echopraxia is mimicking the movements of another person. Echolalia is mimicking the speech of another person.

Question 2 of 5

A child is to receive atropine 0.15 mg (1/400 g) as part of his preoperative medication. A vial containing atropine 0.4 mg (1/150 g)/mL is on hand. How much atropine should be given?

Correct Answer: B

Rationale: The answer is correct. 0.4 mg = 1 mL : 0.15 mg = x mL, 0.4x = 0.15, x = 0.15 / 0.4, x = 0.375 or 0.38 mL. Sufficient information is provided to determine the amount of atropine to administer. The amount of atropine available and the amount of atropine ordered is required to determine the amount of atropine to be given.

Question 3 of 5

The nurse is caring for a client with a history of a mastectomy who is receiving chemotherapy. The nurse should monitor the client for:

Correct Answer: A

Rationale: Chemotherapy commonly causes nausea and vomiting, requiring monitoring and antiemetic therapy. Hypertension, weight gain, and fever are less immediate concerns.

Question 4 of 5

A client has been instructed in how to take her nitroglycerin tablets. The nurse giving her instructions knows the client understands the information when she tells her:

Correct Answer: C

Rationale: Headaches may occur after taking nitroglycerin because of vasodilation. The tablets do not need to be refrigerated. The client should carry them with her. The client should contact the physician if repeated doses of nitroglycerin do not relieve the discomfort. Nitroglycerin tablets should be dissolved under the tongue, not swallowed.

Question 5 of 5

The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?

Correct Answer: C

Rationale: Turkey breast is lean and low in saturated fats compared to macaroni and cheese (high in dairy fat) shrimp (moderate cholesterol) and meat sauce (contains beef fat). It is the best choice for a low-fat low-cholesterol diet.

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