Free NCLEX-RN Exam Braindumps (page: 245)

Page 245 of 431

A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of:

  1. Depression
  2. Agitation
  3. Psychotic ideation
  4. Anhedonia

Answer(s): B

Explanation:

(A) Signs of depression would include withdrawal, sadness, morbid thoughts, insomnia, early awakening, etc. (B) These clinical features are classic signs of agitation. (C) Psychotic ideation includes delusional thoughts, bizarre behavior, disorganized thinking, etc. (D) Anhedonia is the inability to experience pleasure.



A 42-year-old client presents with a diagnosis of paranoid schizophrenia. She has become increasingly restless and verbally argumentative, and her speech has become pressured. She is exhibiting signs of:

  1. Depression
  2. Agitation
  3. Psychotic ideation
  4. Anhedonia

Answer(s): B

Explanation:

(A) Signs of depression would include withdrawal, sadness, morbid thoughts, insomnia, early awakening, etc. (B) These clinical features are classic signs of agitation. (C) Psychotic ideation includes delusional thoughts, bizarre behavior, disorganized thinking, etc. (D) Anhedonia is the inability to experience pleasure.



An infant with a congenital heart defect is being discharged with an order for the administration of digoxin elixir every 12 hours. The parents need to be taught when administering digoxin to the infant that:

  1. If the infant vomits within 30 minutes of the digoxin administration, repeat the dose
  2. They need to mix it with formula so the infant swallows it easily
  3. If the infant vomits two or more consecutive doses or becomes listless or anorexic, notify thephysician
  4. If a dose of digoxin is skipped for more than 6 hours, a new timetable for administration must be developed

Answer(s): C

Explanation:

(A) Occasionally the child may vomit. They should not repeat the dose because the amount of digoxin that was absorbed is un-known, and serum levels of digoxin that are too high are more dangerous than those that are temporarily too low. (B) To ensure that the entire dose of digoxin is received, never mix it with food or formula. (C) Vomiting, anorexia, and listlessness are all signs of digoxin toxicity and should be reported to the physician immediately. (D) If a dose is forgotten for more than 6 hours, the nurse should advise the parents to skip that dose and to continue the next dose as scheduled.



An infant with a congenital heart defect is being discharged with an order for the administration of digoxin elixir every 12 hours. The parents need to be taught when administering digoxin to the infant that:

  1. If the infant vomits within 30 minutes of the digoxin administration, repeat the dose
  2. They need to mix it with formula so the infant swallows it easily
  3. If the infant vomits two or more consecutive doses or becomes listless or anorexic, notify thephysician
  4. If a dose of digoxin is skipped for more than 6 hours, a new timetable for administration must be developed

Answer(s): C

Explanation:

(A) Occasionally the child may vomit. They should not repeat the dose because the amount of digoxin that was absorbed is un-known, and serum levels of digoxin that are too high are more dangerous than those that are temporarily too low. (B) To ensure that the entire dose of digoxin is received, never mix it with food or formula. (C) Vomiting, anorexia, and listlessness are all signs of digoxin toxicity and should be reported to the physician immediately. (D) If a dose is forgotten for more than 6 hours, the nurse should advise the parents to skip that dose and to continue the next dose as scheduled.



Page 245 of 431



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Naveen Ahlam commented on November 29, 2024
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