Question

A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

Answer 1

Correct Answers:

Place the client's arm above the level of the heart.

Rationale :

💠 The arm should be positioned at heart level when measuring blood pressure. If the arm is above the heart, the reading will be falsely low; if below the heart, the reading will be falsely high.

💠 Wrapping the cuff snugly and centering it over the brachial artery are correct techniques that ensure accurate readings.

💠 Checking that the gauge starts at zero prevents measurement error.

💠 Teaching must emphasize proper positioning, because it directly affects the accuracy and reliability of the blood pressure measurement.

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Answer 2

Correct Answers:

auscultatory gap

Rationale :

💎 An auscultatory gap is a period of silence that occurs between the Korotkoff sounds when measuring blood pressure.

💎 It may cause the nurse to miss the true systolic pressure (if not palpated first) or misinterpret diastolic pressure.

💎 This gap is most often seen in clients with hypertension and can lead to falsely low systolic or falsely high diastolic readings.

💎 To avoid error, the nurse should palpate the radial pulse while inflating the cuff to determine the true systolic point before auscultation.

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Answer 3

Correct Answers:

check the patient's record to determine his baseline blood pressure.

Rationale :

🌟 The patient’s blood pressure of 98/66 mm Hg is on the lower side, but whether it is abnormal depends on the patient’s baseline. Some adults naturally have lower BPs without symptoms.

🌟 The radial pulse is 76 (which is normal rate) but irregular, so further assessment is warranted, including reviewing medications and possibly obtaining an ECG.

🌟 The client is alert and oriented with stable respirations, showing no acute distress, so the immediate priority is assessment and comparison to baseline before escalating.

🌟 Notifying the provider or charge nurse comes after confirming this is a change from baseline and correlating with other clinical findings.

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Answer 4

Correct Answers:

Uses physical appearance to gain attention.

Rationale :

💠 Clients with histrionic personality disorder are characterized by excessive emotionality and attention-seeking behaviors.

💠 They often use physical appearance, dramatization, or flirtatious behavior to draw attention to themselves.

💠 They can be easily influenced, have rapidly shifting emotions, and may exaggerate closeness in relationships.

💠 The other options describe traits of different personality disorders (e.g., lack of empathy → antisocial; inferiority → avoidant; manipulation for gain → antisocial).

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Answer 5

Correct Answers:

The client paces in the hallway during the day and most of the night.

Rationale :

💎 In mania, excessive physical activity and lack of sleep put the client at high risk for exhaustion and physical collapse, which can be life-threatening.

💎 While hostility, giving away money, and flight of ideas are concerning behavioral and safety issues, they are not immediate physiological priorities.

💎 According to Maslow’s hierarchy of needs, physiologic stability (rest, nutrition, hydration, sleep) comes before psychosocial concerns.

💎 Addressing constant pacing and lack of rest helps prevent cardiac strain, malnutrition, and severe fatigue.

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Answer 6

Correct Answers:

Impaired gait
Fidgeting behavior
Muscle contractions of the neck

Rationale :

🔶Impaired gait

📌Chlorpromazine (a first-generation antipsychotic) blocks dopamine D₂ receptors in the nigrostriatal pathway, producing drug-induced parkinsonism.

📌Hallmark findings include bradykinesia, rigidity, resting tremor, and a shuffling/propulsive gait—hence “impaired gait.”

📌Nursing priorities: assess fall risk, provide assistance with ambulation, and notify the provider. Management often includes anticholinergics (e.g., benztropine, trihexyphenidyl) or amantadine; dose reduction may be considered.

🔶Fidgeting behavior

📌Persistent inner restlessness with inability to sit still, pacing, foot tapping, and “fidgeting” is classic akathisia, an EPS that can appear days to weeks after starting or increasing the dose.

📌It is frequently misread as anxiety or agitation; careful assessment ties it to antipsychotic therapy.

📌Management may include beta-blockers (e.g., propranolol), benzodiazepines, or anticholinergics; collaborate with the prescriber about dose changes.

🔶Muscle contractions of the neck

📌Sustained, painful muscle spasms—especially torticollis (neck), oculogyric crisis (upward eye deviation), jaw or tongue spasms—indicate acute dystonia, an early-onset EPS (often hours to days after initiation).

📌This can be frightening and may compromise the airway if laryngeal muscles are involved.

📌Treat promptly with IM/IV diphenhydramine or benztropine, then maintain coverage with scheduled anticholinergics to prevent recurrence; ensure airway safety and rapid provider notification.

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Answer 7

Correct Answers:

Planning to give his CD collection to his girlfriend

Rationale :

🔷 Giving away possessions is a classic behavioral indicator of suicidal intent because it reflects preparation for death and desire to settle affairs.

🔷 This action demonstrates emotional detachment and closure-seeking, suggesting the adolescent may be planning or expecting not to be around.

🔷 Such behavior increases the likelihood of imminent risk and therefore requires immediate evaluation of safety and removal of means.

🔷 The nurse should respond with a thorough suicide risk assessment, notify the health care team/parents, and implement protective interventions right away.

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Answer 8

Correct Answers:

Awareness of potential for self-harm

Rationale :

💎 Clients with borderline personality disorder (BPD) have a high risk for impulsive behaviors and self-injury, making safety the top priority for the family to understand.

💎 Teaching families to recognize warning signs of self-harm (such as sudden mood shifts, withdrawal, or giving away possessions) ensures prompt intervention.

💎 Emphasis on safety aligns with the Maslow’s hierarchy of needs, where preservation of life and prevention of harm take precedence over other needs.

💎 Once safety is addressed, the nurse can then expand education to include therapy resources, medication adherence, and financial considerations.

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Answer 9

Correct Answers:

2

Rationale :

📌 Step 1: Identify what is ordered

Provider’s order: clonazepam 1 mg PO

Desired dose (D) = 1 mg

📌 Step 2: Identify what is available

Stock supply: 0.5 mg per tablet

Have (H) = 0.5 mg

📌 Step 3: Apply the formula

Number of tablets=D÷H

Number of tablets=1÷0.5

📌 Step 4: Solve

Number of tablets=2

📌 Step 5: Round if necessary

Already a whole number.

✅ Final Answer: 2 tablets

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Answer 10

Correct Answers:

Dependent personality disorder

Rationale :

⭐ Dependent personality disorder is characterized by an excessive need to be taken care of, leading to submissive and clinging behavior and an overwhelming fear of separation.

⭐ Clients with this disorder often show an inability to make everyday decisions without excessive advice or reassurance from others.

⭐ They typically lack self-confidence and rely on others for validation, direction, and support, which matches the behaviors described in the scenario.

⭐ In contrast, schizoid involves detachment, avoidant involves fear of rejection, and antisocial involves disregard for others—none of which fit the presentation of constant reassurance-seeking and inability to decide independently.

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QLexNursing

1 :
A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

2 :
If a silence is heard between sounds when auscultating blood pressure, it is termed a(n)

3 :
A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

4 :
A nurse is collecting data from a client who has histrionic personality disorder. Which of the following characteristics should the nurse expect?

5 :
A nurse is collecting data from a client who has bipolar disorder with mania. Which of the following findings is the nurse's priority?

6 :
A nurse is collecting data from a client who is taking chlorpromazine. Which of the following findings should the nurse identify as extrapyramidal symptoms (EPS)? (Select all that apply.)

7 :
A nurse is making a home visit for a 16-year-old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?

8 :
A nurse is reinforcing teaching with the family of a client who has a new diagnosis of borderline personality disorder about the disorder. Which of the following information should be the nurse's priority?

9 :
A nurse is preparing to administer clonazepam 1 mg PO. Available is clonazepam 0.5 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

10 :
A nurse is caring for a client who is unable to make any decisions for themself and needs constant reassurance. The nurse should identify that these are manifestations of which of the following personality disorders?

QLexNursing

1 : A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

2 : If a silence is heard between sounds when auscultating blood pressure, it is termed a(n)

3 : A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

4 : A nurse is collecting data from a client who has histrionic personality disorder. Which of the following characteristics should the nurse expect?

5 : A nurse is collecting data from a client who has bipolar disorder with mania. Which of the following findings is the nurse's priority?

6 : A nurse is collecting data from a client who is taking chlorpromazine. Which of the following findings should the nurse identify as extrapyramidal symptoms (EPS)? (Select all that apply.)

7 : A nurse is making a home visit for a 16-year-old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?

8 : A nurse is reinforcing teaching with the family of a client who has a new diagnosis of borderline personality disorder about the disorder. Which of the following information should be the nurse's priority?

9 : A nurse is preparing to administer clonazepam 1 mg PO. Available is clonazepam 0.5 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

10 : A nurse is caring for a client who is unable to make any decisions for themself and needs constant reassurance. The nurse should identify that these are manifestations of which of the following personality disorders?

1 :
A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?

2 :
If a silence is heard between sounds when auscultating blood pressure, it is termed a(n)

3 :
A 45-year-old patient who is alert and oriented has a blood pressure of 98/66 mm Hg, radial pulse of 76 beats/min (irregular), and respirations of 18 breaths/min (regular). The best nursing intervention is to:

4 :
A nurse is collecting data from a client who has histrionic personality disorder. Which of the following characteristics should the nurse expect?

5 :
A nurse is collecting data from a client who has bipolar disorder with mania. Which of the following findings is the nurse's priority?

6 :
A nurse is collecting data from a client who is taking chlorpromazine. Which of the following findings should the nurse identify as extrapyramidal symptoms (EPS)? (Select all that apply.)

7 :
A nurse is making a home visit for a 16-year-old adolescent who attempted suicide. Which of the following behaviors should alert the nurse that the adolescent still has suicidal intent?

8 :
A nurse is reinforcing teaching with the family of a client who has a new diagnosis of borderline personality disorder about the disorder. Which of the following information should be the nurse's priority?

9 :
A nurse is preparing to administer clonazepam 1 mg PO. Available is clonazepam 0.5 mg tablets. How many tablets should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

10 :
A nurse is caring for a client who is unable to make any decisions for themself and needs constant reassurance. The nurse should identify that these are manifestations of which of the following personality disorders?