A nurse assesses a client suspected of having the diagnosis of major depressive episode. Which client symptom would rule out this diagnosis?
1. The client is disheveled and malodorous.
2. The client refuses to interact with others and isolates self in room.
3. The client is unable to feel any pleasure.
4. The client has maxed-out charge cards and exhibits promiscuous behaviors.
4
Rationale: The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous behavior is exhibiting signs of mania. The DSM-5 criteria state that there must never have been a manic episode or a hypomanic episode to meet the criteria for the diagnosis of major depressive episode.
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The mother of a newborn is learning about immunization schedules. The nurse tells this mother her child will ideally receive the immunization for measles, mumps, and rubella (MMR) on what schedule?
A) 2 months, 4 months, between 6 and 18 months, and between 4 and 6 years B) 2 months, 4 months, 6 months, and between 12 and 15 months C) Between 12 and 15 months and between 4 and 6 years D) Between 24 months and 18 years of age
The nurse is preparing to draw blood from a client who states, "Oh, I hate needles. I hope I don't faint this time." The nurse should take which actions?
1. Have another nurse present. 2. Be sure to have aromatic spirits available. 3. Keep the client distracted while drawing the blood. 4. Ensure that the client is in a recumbent position.
A measurement of the quality of food protein based on the amount that is retained in the body after digestion, absorption, and excretion is
a. biologic value. b. amino acid score. c. protein efficiency ratio. d. urinary urea excretion.
What is the unique focus of nursing implementation?
A) Client response to health and illness B) Client response to nursing diagnosis C) Client compliance with treatment regimen D) Client interview and physical assessment