Question

A nurse is collecting data on a client who is admitted to the inpatient mental health unit. The client is complaining of sleep disturbances, feelings of helplessness, and a loss of appetite. The nurse recognizes these symptoms to be indicative of

Answer 1

Correct Answers:

depression.

Rationale :

😴Depression often presents with sleep disturbances, such as difficulty falling or staying asleep.

😔Clients with depression frequently experience feelings of helplessness and hopelessness that affect their outlook.

🍽️A notable loss of appetite or significant weight change is a diagnostic indicator of depressive disorders.

👉These symptoms reflect a mood disorder rather than the heightened energy of bipolar mania, the persistent false beliefs of a delusional disorder, or the excessive worry typical of anxiety.

📌Core Message

Clients with depression exhibit sleep disturbances, feelings of helplessness, and appetite changes.

Answer 2

Correct Answers:

225 mL

Rationale :

💧An adult’s typical maintenance IV fluid rate is about 150 mL/hr.

⏰From 0930 to 1100 is 1.5 hours, so at 150 mL/hr the infusion delivers 225 mL.

🧮Clinical calculations for maintenance fluids often round to the nearest available infusion rate, confirming 225 mL fits the timeframe.

🩺This distinguishes it from smaller or larger volumes, confirming the correct choice is 225 mL, not 200, 250, or 275 mL.

📌Core Message

An adult maintenance infusion at 150 mL/hr over 1.5 hours delivers 225 mL.

Answer 3

Correct Answers:

Perform a bladder scan
Increase IV fluid rate.

Rationale :

🔍Assessing urinary output with a bladder scan detects retention or oliguria from dehydration.

💧Vomiting for three days causes fluid losses, so increasing IV fluids restores intravascular volume.

❌Irrigating the NG tube and high wall suction address obstruction, not dehydration with prerenal azotemia.

💡Administering diuretics without correcting volume can worsen acute kidney injury.

📌Core Message

Monitoring urinary output with a bladder scan and correcting dehydration by increasing IV fluids are essential.

Answer 4

Correct Answers:

Magnesium sulfate
Calcium gluconate

Rationale :

🌡️Prolonged vomiting can lead to magnesium depletion, and since Mr. Anderson has been vomiting for three days, magnesium sulfate is indicated to correct hypomagnesemia.

💓Oliguria from acute kidney injury increases the risk of hyperkalemia, which can cause life-threatening dysrhythmias, so calcium gluconate is administered to stabilize cardiac membranes.

🩸Administering magnesium sulfate also helps stabilize smooth muscle and can reduce potential arrhythmias in the setting of electrolyte imbalance.

⚠️Avoiding potassium‐containing medications is critical because impaired renal excretion worsens hyperkalemia, making calcium gluconate the priority for cardiac protection.

📌Core Message

Correcting hypomagnesemia and using calcium gluconate to protect cardiac function are essential in AKI with ongoing vomiting.

Answer 5

Correct Answers:

Apply oxygen via nasal cannula.
Obtain a chest x-ray.

Rationale :

😷Sudden shortness of breath and productive cough after a fluid bolus indicate pulmonary edema.

📸Ordering a chest x‐ray confirms the presence of fluid overload in the lungs.

🩺Applying oxygen improves oxygenation when alveoli are flooded with fluid.

🚫Reducing furosemide dose, renal biopsy, and thoracentesis are inappropriate; diuresis—not dose reduction—is indicated, and fluid is intrapulmonary, not pleural.

📌Core Message

Fluid overload from an IV bolus can cause pulmonary edema, requiring oxygen support and a chest x‐ray to confirm.

Answer 6

Correct Answers

IV contrast dye injection [ Acute Kidney Injury (AKI) ]
IV 0.9% sodium chloride bolus [ Pleural Effusion ]
NPO status [ Acute Kidney Injury (AKI) ]
Chemotherapy [ Acute Kidney Injury (AKI) ; Pleural Effusion ]
Vomiting [ Acute Kidney Injury (AKI) ]

Rationale :

🩸Contrast media are nephrotoxic, directly injuring renal tubules and reducing perfusion, leading to AKI.

🚰A large‐volume saline bolus increases intravascular volume and can overload cardiac output, predisposing to pleural effusion.

🚫NPO status causes dehydration and decreased renal blood flow, which is a primary driver of prerenal AKI.

💊Chemotherapy agents can be nephrotoxic and also cause capillary leak syndrome, contributing to both AKI and pleural effusion.

🤢Vomiting leads to ongoing fluid losses and electrolyte disturbances that can precipitate AKI.

📌Core Message

Factors that reduce renal perfusion or are nephrotoxic primarily contribute to acute kidney injury, whereas interventions or conditions that increase intravascular volume predispose to pleural effusion.

Answer 7

Correct Answers:

Denial

Rationale :

🛡️Denial is a defense mechanism whereby clients refuse to acknowledge a distressing reality.

🤰Hearing that the infant is “perfectly fine” despite a known congenital diagnosis reflects refusal to accept the situation.

👉This stage helps clients temporarily avoid emotional pain by rejecting the truth.

🔄Denial is the first stage of Kubler-Ross’s grief model, occurring before anger or bargaining.

📌Core Message

The statement that the infant is “perfectly fine” reflects denial as an initial protective response to a difficult diagnosis.

Answer 8

Correct Answers:

An 84-year-old client with bilateral pneumonia and a pulse oximetry reading of 91%

Rationale :

🫁A saturation of 91% in pneumonia indicates compromised oxygenation and risk for respiratory decline.

⚖️Although a hemoglobin of 8.6 is low, without signs of instability (e.g., chest pain or hypotension), it is less immediately life‐threatening.

🌡️A postoperative temperature of 100.2°F is low‐grade and suggests mild infection risk but is not as urgent as hypoxia.

💓A heart rate of 114 in a young fracture patient likely reflects pain or mild stress rather than an immediate life‐threatening issue.

📌Core Message

The client with bipulmonary pneumonia and an O₂ saturation of 91% requires priority assessment due to compromised respiratory status.

Answer 9

Correct Answers:

Encouraging the client to express his feelings openly

Rationale :

😢Encouraging open expression allows clients with PTSD to process traumatic memories in a therapeutic environment.

💬Verbalizing emotions helps reduce internal tension and prevents avoidance behaviors that worsen symptoms.

✍️Discussing feelings promotes cognitive restructuring, enabling the client to reframe negative thoughts associated with the trauma.

🤝Providing a safe space for sharing builds trust and reinforces the therapeutic alliance, which is essential for long‐term recovery.

📌Core Message

Encouraging clients with PTSD to share their feelings openly fosters healing, trust, and symptom reduction.

Answer 10

Correct Answers:

loss of personal memories.

Rationale :

🧠Dissociative amnesia is characterized by a sudden inability to recall personal information, often following severe stress or trauma.

❓Clients retain general knowledge and identity, but specific autobiographical memories are inaccessible.

🛡️This memory loss acts as a defense mechanism, protecting the individual from overwhelming emotional distress.

🔍Unlike cognitive decline, mental abilities remain intact; the primary issue is memory retrieval, not intellectual function.

📌Core Message

In dissociative amnesia, clients experience a selective loss of personal memories while maintaining overall cognitive abilities.

1 :
A nurse is collecting data on a client who is admitted to the inpatient mental health unit. The client is complaining of sleep disturbances, feelings of helplessness, and a loss of appetite. The nurse recognizes these symptoms to be indicative of

Correct Answers

7 :
A client delivered an infant with Dandy- Walker syndrome. The nurse overhears the client tell a friend that the infant is "perfectly fine." The nurse knows that this statement indicates that the client is in which stage of grief?

8 :
The nurse on a medical-surgical unit has received a report on a group of clients. Which client should the nurse see first?

9 :
The nurse is participating in the care of a client who is diagnosed with post- traumatic stress disorder (PTSD). Which of the following is the most therapeutic and beneficial intervention for a client diagnosed with PTSD?

10 :
The nurse is assisting in the plan of care for a client with dissociative amnesia disorder. The nurse plans care for a client with

Factor	Acute Kidney Injury (AKI)	Pleural Effusion
IV contrast dye injection
IV 0.9% sodium chloride bolus
NPO status
Chemotherapy
Vomiting

1 : A nurse is collecting data on a client who is admitted to the inpatient mental health unit. The client is complaining of sleep disturbances, feelings of helplessness, and a loss of appetite. The nurse recognizes these symptoms to be indicative of

Correct Answers

7 : A client delivered an infant with Dandy- Walker syndrome. The nurse overhears the client tell a friend that the infant is "perfectly fine." The nurse knows that this statement indicates that the client is in which stage of grief?

8 : The nurse on a medical-surgical unit has received a report on a group of clients. Which client should the nurse see first?

9 : The nurse is participating in the care of a client who is diagnosed with post- traumatic stress disorder (PTSD). Which of the following is the most therapeutic and beneficial intervention for a client diagnosed with PTSD?

10 : The nurse is assisting in the plan of care for a client with dissociative amnesia disorder. The nurse plans care for a client with

1 :
A nurse is collecting data on a client who is admitted to the inpatient mental health unit. The client is complaining of sleep disturbances, feelings of helplessness, and a loss of appetite. The nurse recognizes these symptoms to be indicative of

7 :
A client delivered an infant with Dandy- Walker syndrome. The nurse overhears the client tell a friend that the infant is "perfectly fine." The nurse knows that this statement indicates that the client is in which stage of grief?

8 :
The nurse on a medical-surgical unit has received a report on a group of clients. Which client should the nurse see first?

9 :
The nurse is participating in the care of a client who is diagnosed with post- traumatic stress disorder (PTSD). Which of the following is the most therapeutic and beneficial intervention for a client diagnosed with PTSD?

10 :
The nurse is assisting in the plan of care for a client with dissociative amnesia disorder. The nurse plans care for a client with