Nokea
A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the healthcare provider?
- A. Insomnia
- B. Muscle cramping
- C. Increased appetite
- D. Anxiety
Correct Answer: B
Rationale: The correct answer is B: Muscle cramping. SIADH causes dilutional hyponatremia due to increased ADH release. Demeclocycline is used to block the action of ADH. Muscle cramping can indicate electrolyte imbalances related to hyponatremia, which should be reported to the healthcare provider. Insomnia, increased appetite, and anxiety are not typically associated with the side effects or complications of demeclocycline or SIADH.
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A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which clinical finding is most concerning?
- A. Headache
- B. Prothrombin time (PT) of 15 seconds
- C. Elevated liver enzymes
- D. Peripheral edema
Correct Answer: A
Rationale: The correct answer is A: Headache. In a client with atrial fibrillation taking warfarin (Coumadin), a headache can be indicative of bleeding, which is a serious complication requiring immediate assessment and intervention. Monitoring for signs of bleeding is crucial when on anticoagulant therapy. Choices B, C, and D are not the most concerning. A prothrombin time of 15 seconds is within the therapeutic range for a client on warfarin, elevated liver enzymes may indicate liver dysfunction but are not directly related to the medication's side effects, and peripheral edema is not typically associated with warfarin use or atrial fibrillation in this context.
The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation?
- A. Direct the UAP to measure the emesis while the nurse irrigates the NGT
- B. Stop the NGT feed and notify the healthcare provider
- C. Increase the NGT suction pressure
- D. Elevate the head of the bed
Correct Answer: A
Rationale: During vomiting in a client with an NGT, it is essential for the nurse to direct the UAP to measure the emesis to monitor the output. This helps in assessing the client's condition and response to treatment. Meanwhile, irrigating the NGT can be beneficial to relieve any obstruction that might be contributing to the vomiting. Stopping the NGT feed and notifying the healthcare provider (choice B) is important but not the immediate action needed. Increasing the NGT suction pressure (choice C) is unnecessary and can lead to complications. Elevating the head of the bed (choice D) is a general intervention to prevent aspiration but may not address the immediate issue of managing the vomiting episode and potential tube obstruction.
A client with hyperthyroidism is admitted to the postoperative unit after subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse?
- A. Total calcium 5.0 mg/dL.
- B. Serum sodium 140 mEq/L.
- C. Serum potassium 4.0 mEq/L.
- D. Serum glucose 90 mg/dL.
Correct Answer: A
Rationale: The correct answer is A. A calcium level of 5.0 mg/dL is critically low and could indicate hypoparathyroidism, a possible complication after thyroidectomy. Low calcium levels can lead to tetany, seizures, and cardiac dysrhythmias, requiring immediate intervention. Choices B, C, and D fall within the normal range and do not require immediate intervention in this scenario.
Following a lumbar puncture, a client voices several complaints. What complaint indicates to the nurse that the client is experiencing a complication?
- A. I am having pain in my lower back when I move my legs
- B. My throat hurts when I swallow
- C. I feel sick to my stomach and am going to throw up
- D. I have a headache that gets worse when I sit up
Correct Answer: D
Rationale: The correct answer is D. A post-lumbar puncture headache, ranging from mild to severe, may occur as a result of leakage of cerebrospinal fluid at the puncture site. This complication is usually managed by bed rest, analgesics, and hydration. Choices A, B, and C do not directly indicate complications associated with a lumbar puncture. Pain in the lower back when moving legs, a sore throat when swallowing, and nausea with a feeling of vomiting are not typical complications of lumbar puncture.
The nurse provides feeding tube instructions to the wife of a client with end-stage cancer. The client's wife performs a return demonstration correctly but begins crying and tells the nurse, 'I just don't think I can do this every day.' The nurse should direct further teaching strategies toward which learning domain?
- A. Cognitive.
- B. Affective.
- C. Comprehension.
- D. Psychomotor.
Correct Answer: B
Rationale: The correct answer is B: Affective. The affective domain involves feelings and emotions, which are significant factors in the wife's ability to cope and perform the required care. In this scenario, the wife's emotional response indicates a need for further support and teaching strategies to address her emotional concerns and build her confidence. Choices A, C, and D are incorrect because the issue at hand is not purely cognitive (knowledge), comprehension (understanding), or psychomotor (physical skills), but rather an emotional response that falls under the affective domain.