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Question 1 of 5

The nurse is reviewing the medical record for an adolescent client with major depressive disorder. Which of the following findings would be consistent with the condition? Select all that apply.

Correct Answer: A,B,C,D

Rationale: Excessive sleep, irritability (outbursts), weight loss, and loss of interest in activities (quitting sports) are hallmarks of depression. Acne concern is typical adolescent behavior, not specific to depression.

Question 2 of 5

The physician has ordered an irrigation of the client's left ear for the removal of cerumen. To prevent vestibular stimulation, the fluid should be degrees Fahrenheit:

Correct Answer: C

Rationale: Cerumen is removed using a mixture of water and hydrogen peroxide at body temperature. Answers A and B are incorrect because they are too cold. Answer D is incorrect because it is too hot.

Question 3 of 5

Which finding is commonly noted in the client with bladder cancer?

Correct Answer: A

Rationale: Painless hematuria is a hallmark symptom of bladder cancer, often the earliest sign. Other symptoms may occur but are less specific.

Question 4 of 5

The nurse is caring for a client with type 1 diabetes mellitus who is reporting abdominal pain and weakness. The client has a fruity odor to the breath and rapid, deep respirations. Which of the following actions should the nurse take? Select all that apply.

Correct Answer: B,C,D,E

Rationale: Symptoms suggest diabetic ketoacidosis (DK
A). Checking glucose confirms hyperglycemia, cardiac monitoring detects arrhythmias from electrolyte imbalances, IV insulin corrects hyperglycemia, and saline bolus addresses dehydration. Breathing into a paper bag is for hyperventilation from anxiety, not DKA.

Question 5 of 5

The nurse is preparing to administer ear drops to an adult client. It would require follow-up if the nurse

Correct Answer: B

Rationale: Placing the dropper into the ear canal risks injury and contamination. Ear drops should be instilled by holding the dropper above the canal. Other actions are correct: room-temperature drops prevent discomfort, pulling the pinna straightens the canal, and a cotton ball retains the medication.

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