A young adult male who is being seen at the employee health care clinic for an annual assessment tells the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficult indeed. Which response is best for the nurse to provide?- Nurselytic

Question 1 of 5

A young adult male who is being seen at the employee health care clinic for an annual assessment tells the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficult indeed. Which response is best for the nurse to provide?

A. Ask the client if he is worried about becoming schizophrenic at the age his mother was diagnosed. B. Encourage the client to seek genetic counseling to determine his risk for mental illness. C. Inform the client that his mother's schizophrenia has affected his psychological development. D. Tell the client that mental illness has a familial predisposition so he should see a psychiatrist.

Correct Answer: B

Rationale: Genetic counseling can help assess risk and provide guidance for the client's concerns about potential hereditary conditions.

Question 2 of 5

The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instructions should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse?

A. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete B. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion C. Monitor the client carefully for the next three hours and report the onset of a reaction immediately D. Notify the nurse when the transfusion has finished, so further client assessment can be done

Correct Answer: A

Rationale: The correct instruction for the UAP is to continue measuring the client's vital signs every thirty minutes until the transfusion is complete. This is important because continuous monitoring of vital signs during the transfusion helps detect any delayed reactions promptly. Choice B is incorrect because maintaining client comfort is important but not the priority over monitoring vital signs. Choice C is incorrect as monitoring should be ongoing and not limited to a specific time frame. Choice D is incorrect as the UAP should monitor vital signs throughout the transfusion, not just at the end.

Question 3 of 5

A client with active tuberculosis (TB) is receiving isoniazid (INH) and rifampin (RMP) daily, so direct observation therapy (DOT) is initiated while the client is hospitalized. Which instruction should the nurse provide this client?

A. Describe feelings about taking daily medications B. Take medications in the presence of the nurse C. Notify the nurse after self-medication is completed D. Keep a daily record of all medications taken

Correct Answer: B

Rationale: The correct instruction for the nurse to provide the client undergoing direct observation therapy for TB is to take medications in the presence of the nurse. This approach ensures that the client is actually taking the medications as prescribed, reducing the risk of noncompliance. Choice A is incorrect because the focus should be on ensuring the client physically takes the medications rather than discussing feelings. Choice C is incorrect as it does not ensure direct observation. Choice D is incorrect because self-reporting or keeping a record does not guarantee that the client is actually taking the medications.

Question 4 of 5

A client with multiple sclerosis is experiencing scotomas (blind spots), which are limiting peripheral vision. What intervention should the nurse include in this client's plan of care?

A. Encourage the use of corrective lenses during the day B. Practice visual exercises that focus on a still object C. Alternate an eye patch from eye every 2 hours D. Teach techniques for scanning the environment

Correct Answer: D

Rationale: The correct intervention for a client with multiple sclerosis experiencing scotomas and limited peripheral vision is to teach techniques for scanning the environment. This intervention helps the client compensate for vision loss by learning how to scan and explore their surroundings effectively. Encouraging the use of corrective lenses may not address the issue of scotomas, and visual exercises focusing on a still object may not enhance peripheral vision. Alternating an eye patch every 2 hours is not typically indicated for scotomas in multiple sclerosis, making it an incorrect choice.

Question 5 of 5

The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?

A. Record urine output every hour B. Monitor blood pressure frequently C. Evaluate neurological status D. Maintain seizure precautions

Correct Answer: B

Rationale: Pheochromocytoma is associated with severe hypertension due to excessive catecholamine release. Monitoring blood pressure frequently is the priority intervention to assess for hypertensive crises and prevent complications like stroke, heart attack, or organ damage. While recording urine output every hour, evaluating neurological status, and maintaining seizure precautions are important aspects of care, they are not the highest priority in a client with pheochromocytoma.

Nurselytic

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