Choice A reason: Encouraging interaction with others by having the client share a room might be overwhelming for a client experiencing hypomanic episodes. Hypomania can involve irritability and impulsivity, making shared spaces potentially stressful. It's important to balance social interaction with the need for a controlled environment.

Choice B reason: Providing a calm atmosphere by placing the client in a private room can be beneficial for someone experiencing hypomanic episodes. A private room can reduce overstimulation and help manage symptoms like restlessness, agitation, and sleep disturbances. It allows the client to have a quiet space to retreat to, which can be crucial in managing mood swings.

Choice C reason: While a cheerful environment may seem beneficial, having bright drapes in the client's room could potentially contribute to overstimulation. Clients with hypomania are often sensitive to environmental stimuli, so it's important to keep the setting subdued to avoid exacerbating symptoms.

Choice D reason: Promoting access to activities by assigning the client to a room near the dayroom can be a double-edged sword. While it facilitates engagement in structured activities, which can be therapeutic, it also increases the risk of overstimulation due to the proximity to a potentially busy and noisy area. Careful consideration of the client's current state is necessary when making this decision.

Choice A reason: Obsessive-Compulsive Disorder (OCD) is characterized by persistent, unwanted thoughts (obsessions) and behaviors (compulsions) that the individual feels the urge to repeat over and over. While OCD is a separate condition that can co-occur with many disorders, it is not commonly associated as a comorbidity with histrionic personality disorder.

Choice B reason: Schizophrenia is a severe mental disorder that affects how a person thinks, feels, and behaves. It is not typically associated with histrionic personality disorder, which is characterized by excessive emotionality and attention-seeking behaviors.

Choice C reason: Generalized Anxiety Disorder (GAD) is a common comorbidity with histrionic personality disorder. Individuals with histrionic personality disorder may experience high levels of anxiety, which can manifest as GAD. This anxiety often relates to fears of rejection or not being the center of attention.

Choice D reason: Anorexia Nervosa is an eating disorder characterized by an abnormally low body weight, intense fear of gaining weight, and a distorted perception of body weight. It is more commonly associated with other conditions, such as obsessive-compulsive and avoidant personality disorders, rather than histrionic personality disorder.

Choice A reason: The statement that the antidote for warfarin is protamine is incorrect. The primary antidote for warfarin is Vitamin K, and in cases of significant bleeding, prothrombin complex concentrate (PCC) or fresh frozen plasma (FFP) may be used¹². Protamine is used as an antidote for heparin, not warfarin.

Choice B reason: Observing the client for manifestations of hemorrhage is a critical nursing action when administering warfarin. Warfarin is an anticoagulant, and one of the major risks associated with its use is bleeding. The nurse should monitor for signs such as unusual bruising, petechiae, hematuria, tarry stools, or any other indications of internal or external bleeding.

Choice C reason: Monitoring the client's aPTT (activated partial thromboplastin time) is not typically associated with warfarin therapy. Warfarin's effect is monitored through the prothrombin time (PT) and the International Normalized Ratio (INR), not aPTT, which is more commonly used to monitor heparin therapy.

Choice D reason: Warfarin should not be administered along with NSAIDs without careful consideration and monitoring due to the increased risk of bleeding. NSAIDs can affect platelet function and gastrointestinal mucosa, leading to an elevated risk of gastrointestinal bleeding when taken with warfarin.

Choice A reason: Monitoring daily weight can help detect early signs of lithium toxicity, as sudden weight gain may indicate fluid retention, which is a concern with lithium treatment. It is important for clients to monitor their weight regularly to ensure no significant fluctuations occur that could suggest adverse effects.

Choice B reason: Avoiding foods with high tyramine content is not specifically related to lithium therapy. This dietary restriction is more commonly associated with monoamine oxidase inhibitors (MAOIs), a different class of psychiatric medications. Lithium does not interact with tyramine in the same way.

Choice C reason: Limiting daily fluid intake is not recommended for clients taking lithium unless otherwise directed by a healthcare provider. Adequate fluid intake is essential to prevent dehydration, which can increase lithium levels and the risk of toxicity. Clients should maintain a consistent intake of fluids unless they have a condition that requires fluid restriction.

Choice D reason: Following a low sodium diet is not advised for clients on lithium therapy. Lithium is processed in the body similarly to sodium, so if sodium levels are too low, lithium retention may increase, leading to toxicity. Clients should maintain a consistent, adequate intake of sodium to prevent fluctuations in lithium levels.

Choice A reason: Methadone is an opioid used primarily for opioid maintenance therapy and to relieve severe pain, not typically for alcohol withdrawal. It does not address the specific symptoms associated with alcohol withdrawal such as seizures or delirium tremens.

Choice B reason: Salicylates, such as aspirin, are not used to treat alcohol withdrawal. They can increase the risk of bleeding, especially in the gastrointestinal tract, which can be a concern in individuals with a history of heavy alcohol use.

Choice C reason: Benzodiazepines, such as chlordiazepoxide, are the first-line treatment for alcohol withdrawal. They help reduce the risk of seizures, ease withdrawal symptoms, and can prevent the progression to more severe forms of withdrawal such as delirium tremens.

Choice D reason: Diphenhydramine is an antihistamine with sedative properties, but it is not a first-line medication for alcohol withdrawal. While it may provide some sedation, it does not prevent seizures or other serious complications of alcohol withdrawal.

Choice A reason: Tetany and stiffness of the hands are not typical symptoms of hypothyroidism. Tetany is usually associated with hypocalcemia, which is not a direct result of hypothyroidism.

Choice B reason: Exophthalmos and nervousness are symptoms associated with hyperthyroidism, not hypothyroidism. Exophthalmos, the bulging of the eyes, is particularly associated with Graves' disease, a type of hyperthyroidism.

Choice C reason: Extreme fatigue and hair loss are common symptoms of hypothyroidism. The condition can lead to a slowing down of the body's metabolic processes, resulting in fatigue. Hair loss is also a frequent complaint due to the effects of reduced thyroid hormone levels on hair follicles.

Choice D reason: Profuse sweating and flushed skin are more indicative of hyperthyroidism or other conditions, not hypothyroidism. Hypothyroidism typically leads to cold intolerance and dry skin.

Choice A reason: The statement is correct; even with sterile precautions, there is a risk of infection. It's important for clients to understand this risk and recognize signs of infection early.

Choice B reason: This statement is incorrect and indicates a misunderstanding. The volume of the output solution should be equal to or slightly less than the input solution due to fluid removal from the body.

Choice C reason: The fluid from the abdomen should indeed be clear or slightly yellow. Cloudy or discolored fluid can indicate an infection or other complication.

Choice D reason: Using a microwave to warm the solution is not recommended as it can lead to uneven heating and potentially damage the solution. The solution should be warmed to body temperature using a warming device designed for this purpose.

Choice A reason: While morphine IV can be used to alleviate pain and anxiety, it is not the first-line intervention for a pulmonary embolism. The primary concern in pulmonary embolism is to address the impaired gas exchange and potential hypoxemia.

Choice B reason: Starting an IV infusion of lactated Ringer's may be part of the overall management but is not the immediate priority. The initial focus should be on stabilizing the client's respiratory status.

Choice C reason: Initiating cardiac monitoring is important for observing the client's heart function, as pulmonary embolism can lead to strain on the heart. However, the first intervention should be to ensure adequate oxygenation.

Choice D reason: Administering oxygen therapy is the most critical initial intervention for a client with a pulmonary embolism. Oxygen therapy helps to manage hypoxemia and reduce the workload on the heart by improving oxygen saturation levels.

Choice A reason: Standard precautions are the primary strategy for the prevention and control of hepatitis C virus (HCV) transmission. According to the Centers for Disease Control and Prevention (CDC), standard precautions include hand hygiene and the use of personal protective equipment to prevent contact with blood and other potentially infectious materials. Since HCV is primarily transmitted through blood-to-blood contact, standard precautions are sufficient for routine care of patients with hepatitis C.

Choice B reason: Airborne precautions are not necessary for hepatitis C as it is not spread through the air. These precautions are used for diseases that are transmitted through airborne droplet nuclei or dust particles containing the infectious agent, such as tuberculosis, measles, or chickenpox.

Choice C reason: Droplet precautions are also not required for hepatitis C because it is not spread through droplets in the air. Droplet precautions are used for infections that can be transmitted through large droplets expelled during coughing, sneezing, talking, or during procedures such as suctioning and bronchoscopy.

Choice D reason: Contact precautions are not specifically required for hepatitis C unless there is a risk of blood contamination. Contact precautions are typically used for infections that are spread by direct or indirect contact with the patient or the patient's environment, such as gastrointestinal, respiratory, skin, or wound infections.

Choice A reason: Tarry stools, also known as melena, can be a sign of gastrointestinal bleeding, which may occur in cirrhosis due to the development of esophageal varices. However, it is not a direct symptom of cirrhosis itself but rather a complication that can arise from the condition.

Choice B reason: Blood in the urine is not a typical finding associated with cirrhosis. While cirrhosis can lead to problems with kidney function, hematuria is not a direct symptom of liver disease and may indicate other urological conditions.

Choice C reason: Moist skin is not commonly associated with cirrhosis. Patients with cirrhosis often experience skin changes, but these typically include jaundice, bruising, and spider angiomas, not increased moisture of the skin.

Choice D reason: Spider angiomas are a common finding in cirrhosis. They are small, spider-like capillaries visible under the skin and are caused by the increased estrogen levels that occur due to the liver's inability to metabolize hormones properly. They are most often found on the face, neck, upper chest, and arms.

Choice A reason: Tongue thrusting and lip smacking are classic signs of tardive dyskinesia (TD), a side effect of long-term use of dopamine receptor-blocking agents like haloperidol. TD is characterized by repetitive, involuntary, purposeless movements, primarily affecting the facial, mouth, and tongue muscles.

Choice B reason: Fine hand tremors and pill rolling are more commonly associated with Parkinson's disease, which is a different type of movement disorder. While antipsychotic medications can cause extrapyramidal symptoms that resemble Parkinson's disease, these are not indicative of tardive dyskinesia.

Choice C reason: Urinary retention and constipation can be side effects of antipsychotic medications due to their anticholinergic effects. However, these are not symptoms of tardive dyskinesia, which specifically involves involuntary movements.

Choice D reason: Loud talking and pacing may be related to the underlying condition of acute psychosis or could be a behavioral side effect of antipsychotic medication, but they are not symptoms of tardive dyskinesia.

Choice A reason: While helping the client identify positive personality traits can be beneficial for self-esteem and long-term recovery, it is not the immediate priority during the acute withdrawal phase. The focus during this time should be on managing withdrawal symptoms and ensuring the client's safety.

Choice B reason: Providing for adequate hydration and rest is the priority intervention for a client in alcohol withdrawal. Withdrawal can lead to significant fluid loss due to vomiting and sweating, and rest is essential for the body to recover from the physiological stress of detoxification. Ensuring the client is well-hydrated and rested can prevent complications and aid in the recovery process.

Choice C reason: Educating the client about the consequences of alcohol misuse is an important part of treatment but is not the immediate priority during withdrawal. Education is more effective when the client is stable and can participate actively in learning and discussion.

Choice D reason: Confronting the use of denial and other defense mechanisms may be part of the therapeutic process but is not the immediate priority during the acute phase of withdrawal. The nurse's immediate concern should be the physical stabilization of the client.

Choice A reason: The plantar reflex, also known as the Babinski sign, is elicited by stroking the lateral aspect of the sole of the foot. A positive response is indicated by dorsiflexion of the big toe and fanning of the other toes. This reflex is normal in infants but may indicate central nervous system damage in adults. However, it is not specifically associated with meningeal irritation.

Choice B reason: Kernig's sign is a clinical sign wherein the patient experiences severe stiffness of the hamstrings causing an inability to straighten the leg when the hip is flexed to 90 degrees. This sign can indicate meningeal irritation but is not as early a sign as Brudzinski's sign.

Choice C reason: Brudzinski's sign is one of the most indicative signs of meningeal irritation. When the neck is flexed, there is involuntary flexion of the hips and knees. This reflex is an early sign of meningeal irritation and is considered a critical manifestation in assessing meningitis following head trauma.

Choice D reason: Sunsetting eyes, characterized by the downward deviation of the eyes, is associated with increased intracranial pressure, which can occur in conditions like hydrocephalus. While it may be seen in the context of brain injury, it is not a specific sign of meningeal irritation.

Choice A reason: Individuals with OCD often engage in compulsive behaviors, such as picking up after others, to make their environment feel more controlled or tolerable. This behavior is a response to the anxiety produced by their obsessions, which in this case, could be related to cleanliness or order. By controlling their immediate environment, they may feel a temporary relief from their anxiety, even though this relief is often short-lived and the compulsion becomes a repetitive cycle.

Choice B reason: Changing tasks is not typically the goal of compulsive behaviors in OCD. These behaviors are usually very specific and are performed to manage the anxiety associated with particular obsessions. While the individual might switch from one compulsive behavior to another, it is not done with the intention of task variation but rather as a response to shifting obsessive thoughts.

Choice C reason: Compulsive behaviors in OCD are not aimed at increasing social interaction. In fact, these behaviors can often interfere with social activities and relationships, as they can be time-consuming and may make the individual feel embarrassed or ashamed, leading to social isolation.

Choice D reason: Compulsive behaviors can sometimes be a way for individuals with OCD to exert control over other behaviors or thoughts. However, the primary function of these behaviors is to manage the anxiety associated with obsessions, not necessarily to control other unrelated behaviors.

Choice A reason: Cleaning dentures in a denture cup is a standard hygiene practice but does not directly address the low WBC count. While maintaining oral hygiene is important, it is not the most critical action related to the client's immunocompromised state.

Choice B reason: Replacing the water in flower vases daily is a good practice to prevent bacterial growth; however, it is recommended to avoid having flowers or plants in the room of an immunocompromised patient due to the risk of exposure to fungi and bacteria.

Choice C reason: Humidifying the room can be beneficial for respiratory comfort, but it must be done with caution in immunocompromised patients. Humidifiers need to be kept clean to prevent the growth of bacteria and fungi, which could be harmful to a patient with a low WBC count.

Choice D reason: Serving cooked fruit with meals is the correct action because cooking fruit can eliminate potential pathogens that the client's compromised immune system may not be able to handle. Raw fruits and vegetables can harbor bacteria and other pathogens, so serving them cooked is a safer option for someone with a low WBC count.

Choice A reason: Bradykinesia refers to the slowness of movement and is commonly associated with Parkinson's disease, not meningitis. It is characterized by a gradual loss of spontaneous movement and can affect the ability to initiate and continue movements.

Choice B reason: Brudzinski's sign is a clinical sign that suggests meningitis when neck flexion causes reflex flexion of the hips and knees. It occurs due to meningeal irritation caused by spinal cord movement or nerves against the meninges. This sign is considered positive when passive flexion of the neck results in reflex flexion of the hips and knees, indicating meningeal irritation.

Choice C reason: Kernig's sign is another clinical sign used to evaluate for meningitis. It involves extending and straightening one knee while the individual lies on their back with their hips and knees bent at a 90-degree angle. A positive Kernig’s sign indicates pain or resistance when the leg is extended, which suggests meningitis. However, it is not the condition described in the scenario.

Choice D reason: Nuchal rigidity is an inability to flex the neck forward due to rigidity of the neck muscles. While it is a sign of meningitis, it does not involve the involuntary flexion of the legs as described in the scenario. Nuchal rigidity is typically assessed by attempting to flex the patient's neck forward while they are in a supine position.

Choice A reason: Pupillary changes, such as unequal pupil sizes or a sluggish reaction to light, can be a sign of increased ICP. The cranial nerves that control the pupils may be compressed due to the swelling of the brain, leading to these changes.

Choice B reason: Disorientation, including confusion and changes in alertness, can occur with increased ICP as the pressure affects the brain's ability to process information and maintain consciousness.

Choice C reason: Headache is a common symptom of increased ICP. It can be severe and persistent due to the pressure exerted on the meninges and blood vessels within the brain.

Choice D reason: Slurred speech may result from increased ICP if the areas of the brain responsible for speech and muscle control are affected by the pressure.

Choice E reason: Neck pain and stiffness, particularly when trying to flex the neck forward, can be indicative of meningeal irritation, which can be associated with increased ICP.

Choice A reason: Answering questions with nonsensical phrases is a positive symptom of schizophrenia. It reflects disorganized thinking and speech, which can manifest as incoherence or irrelevance in the patient's verbal communication. This symptom can significantly impair the patient's ability to engage in meaningful conversation and is often one of the more noticeable signs of schizophrenia during an assessment.

Choice B reason: Seeing, hearing, or feeling something that is not really there, also known as hallucinations, are hallmark positive symptoms of schizophrenia. These sensory experiences occur without an external stimulus and can involve any of the senses, although auditory hallucinations are the most common in schizophrenia. Hallucinations can be extremely distressing for patients and can lead to difficulties in distinguishing reality from delusion.

Choice C reason: The belief that personal significance is attached to trivial or unrelated external events, known as delusions of reference, is another positive symptom of schizophrenia. Patients may believe that messages are being sent to them through the television, radio, or other public means. This can lead to a profound sense of misunderstanding and isolation as the patient navigates a world they perceive as filled with hidden messages meant specifically for them.

Choice D reason: While trouble staying on a schedule or finishing tasks can be associated with schizophrenia, it is not considered a positive symptom. These issues are more reflective of the negative symptoms of schizophrenia, which include avolition or the lack of motivation to initiate and complete goal-directed activities.

Choice E reason: An inability to socially connect with others is also not a positive symptom but rather a negative symptom of schizophrenia. Negative symptoms represent a loss or a decrease in the ability to initiate plans, speak, express emotion, or find pleasure in everyday life. Social withdrawal and impaired social interaction are common negative symptoms that can be mistaken for introversion or depression.

Choice A reason: Acting as if the hallucination is real can validate the client's false perceptions and potentially reinforce the hallucination. It is important to maintain a sense of reality and not to enter into the client's hallucinatory experience.

Choice B reason: Instructing the client to argue with the voices is not therapeutic. It can increase the client's agitation and anxiety, and it does not help in distinguishing reality from hallucinations.

Choice C reason: While it is important to understand the client's experience, asking direct questions about the hallucination may lead the client to focus more on the hallucination, which can reinforce its presence. The nurse should focus on reality-based topics.

Choice D reason: This is the correct action. The nurse should gently and firmly reassure the client that the hallucination is not real and is a symptom of their illness. This helps to orient the client to reality and can reduce the distress associated with hallucinations.

Choice A reason: Decreasing the client's carbohydrate intake is not typically a priority intervention for cirrhosis and ascites. While managing overall nutrition is important, carbohydrates are a necessary component of a balanced diet and provide essential energy.

Choice B reason: Increasing the client's saturated fat intake is not recommended in cirrhosis and ascites. Saturated fats can contribute to fatty liver disease and worsen liver function. A diet low in saturated fats and high in omega-3 fatty acids is generally advised.

Choice C reason: Decreasing the client's fluid intake is a key intervention for managing ascites in cirrhosis. Ascites is the accumulation of fluid in the peritoneal cavity, and reducing fluid intake can help manage this condition. The goal is to prevent further fluid accumulation and reduce the risk of complications such as spontaneous bacterial peritonitis.

Choice D reason: Increasing the client's sodium intake is not advised for cirrhosis and ascites. Sodium can cause the body to retain water, exacerbating fluid accumulation in the abdomen. A low-sodium diet is typically recommended to help control ascites.

Choice A reason: Fibromyalgia can indeed be associated with migraine headaches. Many individuals with fibromyalgia report experiencing headaches, and migraines are a common comorbidity. The exact link between fibromyalgia and migraines is not fully understood, but it is believed that the same abnormalities in neurotransmitter levels that contribute to fibromyalgia pain may also predispose individuals to migraines.

Choice B reason: The statement "Fibromyalgia causes joint inflammation" is incorrect and indicates a need for further teaching. Fibromyalgia does not cause inflammation within the joints. It is characterized by widespread musculoskeletal pain, fatigue, and tenderness in specific areas, but it does not involve the type of joint inflammation seen in conditions like rheumatoid arthritis. This misconception may arise because the symptoms can be similar to those of arthritic conditions, but the underlying mechanisms are different.

Choice C reason: Fibromyalgia may indeed cause chest pain, which is often referred to as costochondritis when it involves the cartilage of the rib cage. This chest pain can mimic that of a heart attack or other heart conditions, but it is actually a common symptom of fibromyalgia and is related to the tender points in the chest area.

Choice D reason: It is true that fibromyalgia symptoms may worsen depending on the weather. Many patients report that their symptoms flare up in response to changes in weather, temperature, and humidity. However, the reasons for this sensitivity are not entirely clear, and research on the subject has produced mixed results.

Choice A reason: Elevating the head of the bed to 20 degrees can help reduce intracranial pressure by promoting venous drainage from the brain. It is a recommended practice unless contraindicated by other conditions.

Choice B reason: Cleansing the eyes with normal saline every 4 hours is a standard care procedure to maintain eye hygiene and prevent infection, especially when the blink reflex may be compromised in an unconscious patient.

Choice C reason: Lubricating the skin with baby oil is a common practice to prevent dryness and maintain skin integrity. It is not contraindicated unless the patient has specific allergies or skin conditions that require different care.

Choice D reason: Suctioning the oropharynx routinely is contraindicated as it can stimulate the vagus nerve and potentially increase intracranial pressure. Suctioning should be performed cautiously and only when necessary.

Choice A reason: Regular exercise, as tolerated and recommended by a healthcare provider, is beneficial for heart failure patients as it can improve cardiovascular health and overall well-being.

Choice B reason: Taking naproxen sodium for generalized discomfort is not recommended for heart failure patients as nonsteroidal anti-inflammatory drugs (NSAIDs) can worsen heart failure by causing fluid retention and increasing blood pressure.

Choice C reason: Taking diuretics early in the morning is advised to avoid nocturia; however, taking them before bedtime is not recommended for the same reason, as it can disrupt sleep due to the need for frequent urination.

Choice D reason: Patients should be instructed to notify their healthcare provider of a weight gain of 0.5 kg (1 lb) in a week as it may indicate fluid retention, which is a common issue in heart failure.

Choice A reason: Constipation is not commonly reported as an adverse effect of tamoxifen. While it may occur, it is not as prevalent as other side effects such as hot flashes.

Choice B reason: Hot flashes are a well-known and common adverse effect of tamoxifen. They occur due to the antiestrogen effects of the medication, which can disrupt the body's temperature regulation.

Choice C reason: Increased appetite is not typically associated with tamoxifen use. While changes in weight can occur, they are not directly linked to an increase in appetite as a side effect of this medication.

Choice D reason: Insomnia may occur in some individuals taking tamoxifen, but it is not one of the most common adverse effects. Hot flashes and other menopausal-like symptoms are more frequently reported.

Choice A reason: Serum creatinine is a key indicator of renal function. It is a waste product that kidneys filter out. Elevated levels can indicate impaired kidney function, which is a concern in SLE due to the risk of lupus nephritis.

Choice B reason: Urine-specific gravity can provide information about the kidney's ability to concentrate urine but is not as specific as serum creatinine for assessing overall renal function.

Choice C reason: Blood urea nitrogen (BUN) can be influenced by factors other than renal function, such as hydration status and dietary protein intake, making it less reliable than serum creatinine for evaluating kidney function in SLE.

Choice D reason: Serum sodium levels can be affected by various factors, including fluid balance and medications. While it can reflect changes in kidney function, it does not provide as direct an assessment as serum creatinine.