The patient with schizophrenia is sitting quietly in a chair. The patient does not respond much to what is happening and has a lack of interest in the environment. How does the nurse interpret this assessment?

Correct Answer: D

Rationale: Schizophrenia's negative symptoms include apathy and withdrawal, seen in quietness and disinterest . Depression needs more evidence. Voices suggest positive symptoms, absent here. Positive symptoms add behaviors, not subtract. D aligns with schizophrenia's clinical presentation, making it the correct interpretation.

Correct Answer: D

Rationale: Digoxin belongs to the class of drugs known as cardiac glycosides. Cardiac glycosides are a group of compounds derived from plants and some animals that have the ability to increase the contractility of the heart muscle. Digoxin is commonly used to treat conditions such as congestive heart failure and irregular heart rhythms. It works by inhibiting the sodium-potassium pump in heart muscle cells, leading to an increase in intracellular calcium levels and subsequently improving the heart's pumping ability.

Correct Answer: C

Rationale: Codeine, an opioid antitussive, can cause respiratory depression as a side effect. The nurse must assess the patient’s respiratory rate before administration to ensure it is within a safe range (typically >12 breaths per minute). While lung sounds (B) and sputum consistency (D) are important, they are not the priority when administering a medication that can suppress respiration. Pulse oximetry (A) is useful but secondary to direct respiratory rate assessment.

Correct Answer: B

Rationale: Colchicine should be used with caution in patients with aplastic anemia or other blood dyscrasias, as it can exacerbate bone marrow suppression. While colchicine is used to treat conditions like Behcet disease and familial Mediterranean fever, it is not contraindicated in these conditions. Amyloidosis is not a primary concern with colchicine use. Monitoring blood counts is essential in patients with pre-existing hematologic conditions.

Correct Answer: B

Rationale: Risperidone, an atypical antipsychotic, can cause agranulocytosis, a rare but life-threatening drop in white blood cells, necessitating regular blood monitoring . This statement reflects understanding of a critical safety measure, indicating effective education. Nightmares aren't a primary concern with risperidone. Weight loss contrasts with its common side effect of weight gain, making it less relevant. Metallic taste isn't associated with this drug. The nurse evaluates learning based on recognition of monitoring for severe adverse effects like agranulocytosis, ensuring patient safety, making choice B the best indicator of comprehension.

Correct Answer: A

Rationale: Rotating the application sites of transdermal nitroglycerin patches is important to prevent skin irritation and tolerance development. By changing the site with each dose, the nurse ensures proper absorption of the medication and reduces the risk of skin reactions. It is not recommended to always apply the patch to the same site, as this can lead to localized skin irritation. It is also important to avoid using areas with a lot of hair or bony prominences, as well as to avoid areas with scars or skin folds. Rotation of application sites helps maintain the effectiveness of the nitroglycerin patch therapy.

Correct Answer: D

Rationale: Packed red blood cells (PRBCs) are the most appropriate product to administer after a severe auto accident when there is significant blood loss and anemia. PRBCs are used to increase the oxygen-carrying capacity of the blood and improve tissue oxygenation. They are specifically designed to deliver red blood cells without the unnecessary components found in whole blood. This targeted approach helps to avoid volume overload and reduce the risk of complications such as transfusion reactions. In a trauma situation where there is active bleeding and a need to rapidly restore oxygen-carrying capacity, PRBCs are the preferred blood product.

Correct Answer: C

Rationale: Prednisone, a corticosteroid, manages inflammation but risks serious side effects. Blurred vision may signal glaucoma or cataracts, ocular emergencies requiring immediate reporting to prevent vision loss. Increased appetite and weight gain are common, manageable effects of cortisol excess. Mood swings occur due to CNS effects but are less urgent unless severe. Blurred vision stands out as a rare but critical adverse reaction, linked to prednisone's long-term impact on intraocular pressure or lens opacity. Teaching this ensures early detection, aligning with corticosteroid monitoring where eye complications can escalate fast. Appetite, weight, and mood changes, while disruptive, don't match this urgency, making C the priority side effect for the client to report promptly.

Correct Answer: D

Rationale: Patients taking Angiotensin-converting enzyme (ACE) inhibitors should avoid salt substitutes, foods high in potassium, and foods high in sodium. Salt substitutes often contain potassium chloride, which may cause an increase in potassium levels when combined with ACE inhibitors. Foods high in potassium, such as bananas, oranges, spinach, and potatoes, can also potentially elevate potassium levels when consumed in large amounts. Additionally, foods high in sodium can counteract the effects of ACE inhibitors in managing blood pressure. Therefore, it is important for patients on ACE inhibitors to be mindful of their intake of salt substitutes, high-potassium foods, and high-sodium foods to ensure the effectiveness of their medication and to prevent any potential complications.