Marge is a 68-year-old woman with a long history of bipolar disorder. She is brought to the ED by her sister, who reports that Marge has been increasingly agitated, unable to sleep, and told her daughter that the mayor was calling her for advice on running the city. The behavior is an example of:

Schizophrenia

Auditory hallucinations

Delusions of grandeur

Delusions of persecution

Answer and Explanation

The Correct Answer is C

Choice A reason: Schizophrenia is a diagnosis, not a symptom, and involves a range of symptoms including delusions, hallucinations, and disorganized thinking.

Choice B reason: Auditory hallucinations involve hearing voices or sounds that are not there and are not described in the scenario.

Choice C reason: Delusions of grandeur involve beliefs of having more power, wealth, smarts, or other grand traits than is true, which fits the description of Marge's belief about advising the mayor.

Choice D reason: Delusions of persecution involve beliefs that others are out to harm or harass the individual, which is not indicated in Marge's behavior.

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Correct Answer is D

Explanation

Choice A reason: Having the patient sit alone while reviewing rules does not address the immediate risk of injury due to hyperactivity.

Choice B reason: Reinforcing coping mechanisms can help the patient manage hyperactivity and reduce the risk of injury.

Choice C reason: Placing the patient with another hyperactive patient could potentially exacerbate the situation and increase the risk of injury.

Choice D reason: While administering medication may be necessary, it should be done in conjunction with other interventions that address behavior management.

A. Hearing deficits B. Jaundice C. Anorexia D. Ataxia

Correct Answer is C

Explanation

Choice A reason: Hearing deficits are not commonly associated with digoxin toxicity. The typical symptoms involve gastrointestinal, neurological, and visual changes³.

Choice B reason: Jaundice is not a manifestation of digoxin toxicity. It is more commonly related to liver conditions³.

Choice C reason: Anorexia is a common symptom of digoxin toxicity, along with nausea, vomiting, and abdominal pain. These gastrointestinal symptoms are important indicators for nurses to monitor³.

Choice D reason: Ataxia, or lack of muscle coordination, is not a typical sign of digoxin toxicity. The primary concerns with toxicity are cardiac arrhythmias and gastrointestinal symptoms³.

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Marge is a 68-year-old woman with a long history of bipolar disorder. She is brought to the ED by her sister, who reports that Marge has been increasingly agitated, unable to sleep, and told her daughter that the mayor was calling her for advice on running the city. The behavior is an example of:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A newly admitted patient in an acute manic state has a nursing diagnosis of at risk for injury related to hyperactivity. Which nursing intervention is most appropriate?

Correct Answer is D

Explanation

A nurse is collecting data from an older adult client who has been taking digoxin for the past several months. For which of the following manifestations of digoxin toxicity should the nurse monitor?

Correct Answer is C

Explanation

The nurse would evaluate a female patient, age 68, as understanding teaching on the purpose of coronary artery bypass graft surgery if she made which of the following statements?

The nurse reviews the lab test results of a patient who has heart failure (HF). Which test result would be most important for the nurse to report to the healthcare provider (HCP)?

The nurse is reinforcing teaching to the patient about controlling cholesterol with diet. Which of the following dietary actions help reduce cholesterol? Select all that apply.

Ms. S is admitted to your medical unit with a diagnosis of dehydration and a history of depression. She tells you, "I just can't eat, I'm not hungry." What would be your best therapeutic response?

After hospitalization for a myocardial infarction, a patient is placed on a low-sodium diet. In discussing foods allowed on this diet, the nurse would inform the patient that this includes which of the following?

A nurse is caring for a client who has depression and states that she is too tired to get out of bed or dress. Which of the following statements by the nurse is appropriate?

A nurse is reviewing the plan of care for a client who has depression. Which of the following actions should the nurse plan to take?

A patient hospitalized with a myocardial infarction suddenly begins having severe respiratory distress with frothy red sputum. What is the first action for the nurse to take?