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1. While assessing a 70-year-old female client with Alzheimer's disease, the nurse notes deep inflamed cracks at the corners of her mouth. What intervention should the nurse include in this client's plan of care?
- A. Apply a moisturizing cream to the affected areas.
- B. Encourage the client to consume foods rich in vitamin B.
- C. Notify the healthcare provider for further evaluation.
- D. Ensure that the client gets adequate B vitamins in foods or supplements.
Correct answer: D
Rationale: Cracks at the corners of the mouth, known as angular cheilitis, can be a sign of vitamin B deficiency, specifically B2 (riboflavin) or B3 (niacin). The nurse should ensure that the client receives adequate B vitamins through foods rich in these nutrients or supplements to address the deficiency, which can help improve the condition of the client's mouth.
2. A patient with an anxiety disorder is prescribed alprazolam. What is the primary action of this medication?
- A. Increase energy levels
- B. Induce sedation
- C. Elevate mood
- D. Reduce anxiety
Correct answer: D
Rationale: Alprazolam is a benzodiazepine that primarily works by reducing anxiety. It achieves this by enhancing the inhibitory effects of the neurotransmitter GABA in the brain, which leads to a calming effect on the individual. Therefore, the primary action of alprazolam is to decrease anxiety levels rather than increase energy, induce sedation, or elevate mood.
3. The nurse is caring for a client with hyperthyroidism. Which intervention should the nurse implement to manage the client's condition?
- A. Provide a high-calorie diet.
- B. Encourage frequent rest periods.
- C. Restrict fluid intake.
- D. Administer a stool softener.
Correct answer: B
Rationale: Encouraging frequent rest periods is essential in managing hyperthyroidism as it helps address the fatigue and hypermetabolic state commonly associated with this condition. Rest is crucial to support the body's recovery and reduce the stress on the thyroid gland. While nutrition is important in managing hyperthyroidism, providing a high-calorie diet is not the priority intervention. Restricting fluid intake is not typically necessary unless there are specific indications such as heart failure. Administering a stool softener is not directly related to managing hyperthyroidism.
4. The nurse is providing an educational workshop about coronary artery disease (CAD) and its risk factors. The nurse explains to participants that CAD has many risk factors, some that can be controlled and some that cannot. What risk factors should the nurse list that can be controlled or modified?
- A. Gender, obesity, family history, and smoking
- B. Inactivity, stress, gender, and smoking
- C. Cholesterol levels, hypertension, and smoking
- D. Stress, family history, and obesity
Correct answer: C
Rationale: Cholesterol levels, hypertension, and smoking are controllable risk factors for CAD. Managing these factors through lifestyle changes and medical interventions can help reduce the risk of developing coronary artery disease.
5. A client diagnosed with major depressive disorder refuses to get out of bed, eat, or participate in group therapy. Which intervention is most important for the nurse to implement?
- A. Offer the client high-calorie snacks and frequent small meals.
- B. Ask the client why they are not participating in therapy.
- C. Sit with the client and offer support without demanding participation.
- D. Encourage the client to discuss their feelings of hopelessness.
Correct answer: C
Rationale: In cases of major depressive disorder where the client is non-participatory and withdrawn, sitting with the client and providing support without pressuring them to engage in activities like eating or therapy is crucial. This approach respects the client's current state, builds trust, and creates a supportive environment that can eventually lead to the client opening up and accepting help.
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