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Questions 158

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Question 1 of 5

The nurse is trying to help a mother understand what is happening with her son who has recently been diagnosed with paranoid schizophrenia. At present, he is experiencing hallucinations and delusions of persecution and suffers from poor hygiene. The nurse can best help her understand her son's condition by which of the following statements?

Correct Answer: A

Rationale: The most plausible theory to date is that dopamine causes an overstimulation in the brain, which results in the psychotic symptoms.

Question 2 of 5

The client is prescribed methotrexate for rheumatoid arthritis. Which instruction should the nurse include?

Correct Answer: B

Rationale: Methotrexate causes immunosuppression, increasing infection risk, so reporting signs of infection is critical. Milk does not prevent GI upset, photosensitivity is not a primary concern, and methotrexate is taken regularly, not as needed.

Question 3 of 5

Which complaint is frequently expressed by a client with macular degeneration?

Correct Answer: A

Rationale: Macular degeneration affects central vision, impairing activities like sewing or reading that require focused vision. Severe pain with nausea is typical of acute glaucoma, halos suggest cataracts or glaucoma, and veil-like vision loss is more associated with retinal detachment.

Question 4 of 5

A nurse is taking a maternal history for a client at her first prenatal visit. Her pregnancy test was positive, she has two living children, she had one spontaneous abortion, and one infant died at the age of 3 months. Which of the following best describes the client at the present?

Correct Answer: B

Rationale: The client has been pregnant five times (current pregnancy, two living children, one spontaneous abortion, one infant death), delivered three children (two living, one died), and had one abortion.

Question 5 of 5

Provide the 1-minute Apgar score for an infant born with the following findings: Heart rate: Above 100 Respiratory effort: Slow, irregular Muscle tone: Some flexion of extremities Reflex irritability: Vigorous cry Color: Body pink, blue extremities

Correct Answer: A

Rationale: Seven out of a possible perfect score of 10 is correct. Two points are given for heart rate above 100; 1 point is given for slow, irregular respiratory effort; 1 point is given for some flexion of extremities in assessing muscle tone; 2 points are given for vigorous cry in assessing reflex irritability; 1 point is assessed for color when the body is pink with blue extremities (acrocyanosis). For a perfect Apgar score of 10, the infant would have a heart rate over 100 but would also have a good cry, active motion, and be completely pink. For an Apgar score of 8 the respiratory rate, muscle tone, or color would need to fall into the 2-point rather than the 1-point category. For this infant to receive an Apgar score of 9, four of the areas evaluated would need ratings of 2 points and one area, a rating of 1 point.

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