Question

A nurse is calculating a client's fluid intake over the past 8 hr. The client had one 8-02 cup Of coffee. 3 oz Of juice, and 12 oz Of soda. The client's water pitcher had 800 mL and 200 mL remain. The client also had IV fluids infusing at 40 mL/hr via an IV pump. How many mL should the nurse document as the client's total intake for the shift?

Answer 1

Correct Answers:

1610

Rationale :

✍️Step 1 – Convert all oral fluids to mL:

♦️Coffee: 8 oz × 30 = 240 mL

♦️Juice: 3 oz × 30 = 90 mL

♦️Soda: 12 oz × 30 = 360 mL

✍️Step 2 – Calculate water intake:

♦️Pitcher started with 800 mL, with 200 mL remaining, so 600 mL consumed.

✍️Step 3 – Add IV fluids:

♦️Infused at 40 mL/hr × 8 hr = 320 mL.

✍️Step 4 – Total intake:

♦️240 + 90 + 360 + 600 + 320

1,610 mL total intake.

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Answer 2

Correct Answers:

Avoid driving or operating heavy machinery until you know how alprazolam affects you.

Rationale :

🔷Alprazolam is a benzodiazepine that can cause CNS depression, resulting in drowsiness, dizziness, or slowed reflexes.

🔷Clients must be cautioned to avoid driving or using heavy machinery until they understand their individual response to the drug.

🔷The medication has an immediate anxiolytic effect, so relief is expected within hours, not weeks.

🔷Teaching should also emphasize short-term use due to dependence and tolerance risk.

🔷This instruction promotes client safety and prevents injury due to impaired coordination.

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Answer 3

Correct Answers:

Muscle weakness

Rationale :

✔️Anorexia nervosa is characterized by severe calorie restriction and malnutrition, leading to protein and electrolyte depletion, which causes generalized muscle weakness.

✔️The body begins to catabolize muscle tissue for energy due to prolonged starvation, resulting in muscle wasting and fatigue.

✔️Low potassium, magnesium, and phosphate levels further contribute to neuromuscular weakness and potential cardiac complications.

✔️Other common clinical findings include bradycardia, hypotension, lanugo, dry skin, and amenorrhea—all reflecting systemic effects of starvation.

✔️Identifying muscle weakness is vital, as it signals malnutrition severity and the need for nutritional rehabilitation and electrolyte correction.

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Answer 4

Correct Answers:

0.5

Rationale :

✍️Order: 0.0625 mg

✍️Available: 0.125 mg/tablet.

✍️Formula:

♦Desired ÷ Have

♦0.0625 ÷ 0.125

= 0.5 tablet.

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Answer 5

Correct Answers:

3.1

Rationale :

✍🏿Step 1:

✔️Convert weight — 22 lb ÷ 2.2

10 kg.

✍🏿Step 2:

✔️Ordered dose — 10 mg/kg × 10 kg

100 mg.

✍🏿Step 3:

✔️Concentration — 160 mg/5 mL.

✍🏿Step 4:

✔️100mg×5mL÷160mg

=3.125mL

→ 3.1 mL.

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Answer 6

Correct Answers:

"The diathesis-stress model assists in identifying risk factors or vulnerabilities for stress."

Rationale :

🟢The diathesis-stress model explains that mental illness results from the interaction between a person’s vulnerability (genetic/biological) and environmental stressors.

🟢It helps nurses and clinicians identify predispositions that make clients more susceptible to mental disorders when exposed to stress.

🟢Understanding these risk factors guides preventive interventions and early detection of psychological distress.

🟢The model emphasizes that stress alone doesn’t cause mental illness, but triggers it in those with existing vulnerability.

🟢This approach supports holistic mental health care by linking biology and environment.

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Answer 7

Correct Answers:

Substance use disorder
Schizophrenia
Age greater than 45 years old

Rationale :

Substance Use Disorder

🔷Substance use disorder (SUD) is a major independent risk factor for suicide because it impairs judgment, increases impulsivity, and lowers inhibition, making lethal attempts more likely.

🔷Intoxication and withdrawal create rapid mood lability and dysphoria, which can amplify hopelessness and worsen co-occurring depression or anxiety.

🔷Chronic SUD is linked to financial, legal, and relationship stressors, all of which compound suicidality.

🔷Certain substances (e.g., alcohol, opioids, stimulants) are associated with higher lethality due to access to means and physiologic toxicity.

🔷Best practice includes universal screening, brief intervention, and fast-track referral to integrated addiction and mental health care, with safety planning and lethal-means counseling.

Schizophrenia

🔷People with schizophrenia have increased suicide risk, particularly with command hallucinations, persecutory delusions, and post-psychotic insight that fuels despair and demoralization.

🔷Early illness phases, recent hospital discharge, and comorbid depression markedly heighten vulnerability.

🔷Akathisia or side effects from antipsychotics can intensify inner restlessness, contributing to distress and suicidality if untreated.

🔷Nonadherence to medication and substance co-use further increase risk, underscoring the need for adherence support and dual-diagnosis treatment.

🔷Evidence-based strategies include close follow-up after transitions of care, clozapine consideration for persistent suicidality, and structured safety planning with family engagement.

Age > 45 Years

🔷Middle to older age correlates with higher suicide completion rates, influenced by chronic illness, functional decline, and accumulated psychosocial losses.

🔷Individuals >45 often have more lethal means and more determined intent, increasing the fatality of attempts.

🔷Social isolation, widowhood, and financial strain are common in this group and intensify hopelessness and perceived burdensomeness.

🔷Coexisting major depressive disorder, untreated pain, and alcohol misuse are frequent and synergistically elevate risk.

🔷Prevention hinges on routine depression screening, pain management, means-restriction counseling, and active linkage to community and family supports.

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Answer 8

Correct Answers:

Escort the client to her room when she is observed trying to interact with other clients.

Rationale :

🔷Clients in the manic phase of bipolar disorder exhibit pressured speech, hyperactivity, and intrusive behaviors that can disrupt or irritate others.

🔷Escorting the client to a low-stimulation environment minimizes environmental triggers and helps restore control.

🔷This action ensures safety, therapeutic structure, and calmness without punishment.

🔷The nurse maintains firm, consistent limits while using short, clear directions to reduce overstimulation.

🔷Such interventions prevent conflict escalation and promote rest and mood stabilization.

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Answer 9

Correct Answers:

2

Rationale :

✍️Ordered dose: 275 mcg

✍️Available dose: 137 mcg per tablet

✍️ Apply the dosage formula:

✔️Tablets to give=Dose ordered/ Dose available

✔️275/137

=2.007

✍️Rounded to the nearest whole number

2 tablets.

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Answer 10

Correct Answers:

"It sounds like you are motivated to work toward healing. You can view recovery as a process and an outcome when you commit to abstinence."

Rationale :

🟣This response demonstrates therapeutic communication by acknowledging motivation and promoting realistic expectations.

🟣It reinforces the concept that recovery from alcohol use disorder is a lifelong process, achieved through ongoing abstinence and self-management.

🟣The nurse avoids false reassurance and judgment, instead providing supportive, empowering language.

🟣Viewing recovery as both a process (daily effort) and outcome (sustained sobriety) fosters resilience and long-term commitment.

🟣Such communication strengthens trust and readiness for treatment participation.

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QLexNursing

2 :
A nurse is caring for a client who is prescribed alprazolam, a benzodiazepine for managing severe manifestations of anxiety. Which of the following should the nurse prepare to discuss with the client?

3 :
A nurse is assisting with the admission of an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?

4 :
A nurse is preparing to administer triazolam 0.0625 mg PO to an older adult client Who has insomnia. Available is triazolam 0.125 mg tablets. HOW many tablets should the nurse plan to administer? (Round to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

6 :
A nurse is discussing the diathesis-stress model with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the mode?

7 :
A nurse is assisting with the development of a community health education class about suicide prevention. Which of the following information should the nurse identify as risk factors for suicide? (Select all that apply.)

8 :
A nurse is caring for a hospitalized client who has bipolar disorder and is disturbing other clients with incessant talking. Which of the following actions should the nurse take?

9 :
A nurse is preparing to administer levothyroxine 275 mcg PO to a client. The amount available is levothyroxine 137 mcg/tablet. How many tablets should the nurse administer? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

10 :
A nurse is assisting with the admission of a client to the chemical dependency unit. The client asks, "Why do you all say that we alcoholics cannot completely be free of it?" Which of the following responses should the nurse give?

QLexNursing

2 : A nurse is caring for a client who is prescribed alprazolam, a benzodiazepine for managing severe manifestations of anxiety. Which of the following should the nurse prepare to discuss with the client?

3 : A nurse is assisting with the admission of an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?

4 : A nurse is preparing to administer triazolam 0.0625 mg PO to an older adult client Who has insomnia. Available is triazolam 0.125 mg tablets. HOW many tablets should the nurse plan to administer? (Round to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

6 : A nurse is discussing the diathesis-stress model with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the mode?

7 : A nurse is assisting with the development of a community health education class about suicide prevention. Which of the following information should the nurse identify as risk factors for suicide? (Select all that apply.)

8 : A nurse is caring for a hospitalized client who has bipolar disorder and is disturbing other clients with incessant talking. Which of the following actions should the nurse take?

9 : A nurse is preparing to administer levothyroxine 275 mcg PO to a client. The amount available is levothyroxine 137 mcg/tablet. How many tablets should the nurse administer? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

10 : A nurse is assisting with the admission of a client to the chemical dependency unit. The client asks, "Why do you all say that we alcoholics cannot completely be free of it?" Which of the following responses should the nurse give?

2 :
A nurse is caring for a client who is prescribed alprazolam, a benzodiazepine for managing severe manifestations of anxiety. Which of the following should the nurse prepare to discuss with the client?

3 :
A nurse is assisting with the admission of an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?

4 :
A nurse is preparing to administer triazolam 0.0625 mg PO to an older adult client Who has insomnia. Available is triazolam 0.125 mg tablets. HOW many tablets should the nurse plan to administer? (Round to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

6 :
A nurse is discussing the diathesis-stress model with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the mode?

7 :
A nurse is assisting with the development of a community health education class about suicide prevention. Which of the following information should the nurse identify as risk factors for suicide? (Select all that apply.)

8 :
A nurse is caring for a hospitalized client who has bipolar disorder and is disturbing other clients with incessant talking. Which of the following actions should the nurse take?

9 :
A nurse is preparing to administer levothyroxine 275 mcg PO to a client. The amount available is levothyroxine 137 mcg/tablet. How many tablets should the nurse administer? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

10 :
A nurse is assisting with the admission of a client to the chemical dependency unit. The client asks, "Why do you all say that we alcoholics cannot completely be free of it?" Which of the following responses should the nurse give?