A nurse is assisting with an admission interview for a client who has schizophrenia. He tells the nurse that he is receiving special audible messages from the Central Intelligence Agency that no one else is able to hear. The nurse should identify that the client is having which of the following alterations in perception?

Depersonalization

Hallucination

Illusion

Derealization

Answer and Explanation

The Correct Answer is B

A.   Depersonalization is a feeling of detachment from oneself or feeling like one's thoughts, feelings, and actions are not their own. It does not involve perceptual disturbances such as hearing voices.
B.   Hallucination is a sensory perception that occurs in the absence of external stimuli. Auditory hallucinations involve hearing voices or sounds that others do not hear, as described by the client in this scenario.
C.   Illusion is a misinterpretation of a sensory stimulus that is actually present in the environment. It involves a distortion or misperception of sensory information, not the perception of something that is not there, as in the case of hallucinations.
D.   Derealization is a feeling of unreality or detachment from one's surroundings. It involves a distortion in the perception of the external world rather than sensory experiences such as hearing voices.

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Correct Answer is C

Explanation

A. Pitting edema: Pitting edema is a sign of fluid retention and is not specifically associated with hypokalemia.
B. Diplopia: Diplopia refers to double vision and is not typically associated with hypokalemia.
C. Muscle weakness: Hypokalemia can lead to muscle weakness due to the impaired function of skeletal muscles.
D. Hyperactive bowel sounds: Hyperactive bowel sounds can occur in conditions such as diarrhea but are not specific to hypokalemia.

A. Pallor in the exposed portion of the left foot B. Inability to move the left foot C. Increased warmth of the exposed portion of the left foot D. Ecchymosis in the exposed portion of the left foot E. Paresthesia in the left foot

Correct Answer is ["A","B","D","E"]

Explanation

A. Pallor in the exposed portion of the left foot indicates a possible reduction in blood flow, which is a symptom of compartment syndrome.
B. Inability to move the left foot could suggest nerve damage or significant muscle dysfunction, which are potential consequences of compartment syndrome.
C. Increased warmth of the exposed portion of the left foot is not typically a symptom of compartment syndrome. This condition is more commonly associated with coolness due to impaired blood flow rather than increased warmth.
D. Ecchymosis in the exposed portion of the left foot may be indicative of underlying bleeding or bruising, which can increase compartmental pressure and is a symptom of compartment syndrome.
E. Paresthesia in the left foot, such as tingling or a burning sensation, can be a sign of nerve compression or damage, which is consistent with compartment syndrome.

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Naxlex Comprehensive Predictor Exams

A nurse in an urgent care clinic is collecting data from a client who reports having diarrhea for the past 3 days. Which of the following findings indicates hypokalemia?

Correct Answer is C

Explanation

A nurse is collecting data from a client who has a long-leg cast on his left leg and reports severe pain. Which of the following findings should the nurse identify as an indication that the client might have compartment syndrome? (Select all that apply.)

Correct Answer is ["A","B","D","E"]

Explanation

A client who has inoperable cancer tells the nurse that she does not want to pursue the recommended treatment. She asks if the provider can force her to have the treatment. Which of the following is an appropriate response by the nurse?

A nurse is reinforcing teaching with a client about caring for a new colostomy. Which of the following statements should the nurse make?

A nurse has obtained a client's oxygen saturation measurement of 88% on 2 liters of oxygen via nasal cannula. Which of the following actions should the nurse take?

A nurse is collecting data from a client who has substance use disorder and reports recently taking opioids. Which of the following findings should the nurse identify as a manifestation of opioid intoxication?

A nurse is reinforcing teaching with a client about smoking cessation. Which of the following client statements indicates an understanding of the teaching?

A nurse is collecting data from a client who is taking heparin to prevent deep-vein thrombosis and has bloody stools. Which of the following laboratory values should the nurse report to the provider?

A nurse is collecting data for a client following electroconvulsive therapy. Which of the following adverse effects should the nurse expect?

A nurse on a medical unit is admitting a client. Exhibits Select the 5 prescriptions the nurse should anticipate from the provider.