Nokea
A client is receiving scheduled doses of carbidopa-levodopa. The nurse evaluates the medication as having the intended effect if which finding is noted?
- A. Improvement in short-term memory
- B. Improvement in spontaneous activity
- C. Reduction in number of visual hallucinations
- D. Reduction of dizziness with standing
Correct Answer: B
Rationale: Carbidopa-levodopa treats Parkinson's symptoms like bradykinesia, improving spontaneous activity, which is the primary therapeutic goal.
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The nurse is screening clients with major depressive disorder for those at risk for suicide. The nurse should recognize the client at highest risk for suicide is the client with
- A. substance use disorder who is married and participates in community programs
- B. Parkinson disease who is divorced and has recently become unemployed
- C. breast cancer who is married and is newly diagnosed with alcohol use disorder
- D. type 2 diabetes mellitus who is recently divorced and has 3 children
Correct Answer: B
Rationale: Recent unemployment and divorce are significant stressors that increase suicide risk, especially in a client with a chronic condition like Parkinson disease, which can exacerbate depressive symptoms.
The nurse prepares to administer an oral expectorant to a client with pneumonia. The client tells the nurse, 'That pill is too big. I won't be able to swallow it.' What is the best action by the nurse?
- A. Contact the pharmacy and request the liquid form of the medication.
- B. Crush the medication and place it in a small amount of applesauce.
- C. Instruct the client to tuck chin to chest while swallowing the tablet.
- D. Obtain a new prescription for the liquid form of the medication.
Correct Answer: A
Rationale: Contacting the pharmacy for a liquid form addresses the client's difficulty swallowing the pill, ensuring medication adherence without altering the drug inappropriately.
A student nurse is preparing to administer the hepatitis B vaccine to a newborn. Which statement by the student nurse requires the preceptor to provide further teaching?
- A. A 5/8-inch, 25-gauge needle is appropriate for intramuscular injection in newborns.
- B. I will clean the injection site with an antiseptic swab before administration.
- C. I will draw the medication into a 1-mL syringe.
- D. The medication should be administered into the deltoid muscle.
Correct Answer: D
Rationale: The deltoid muscle is not developed enough in newborns for intramuscular injections. The hepatitis B vaccine should be administered in the anterolateral thigh.
The nurse reviews new laboratory results for assigned clients. Which finding is the priority for the nurse to report to the supervising registered nurse?
- A. CD4+ cell count of 600 cells/uL in a client with HIV and oral candidiasis who is receiving PO fluconazole
- B. Hemoglobin A1c of 7.3% in a client with type 2 diabetes and pneumonia who is receiving IV levofloxacin heparin infusion
- C. Serum glucose of 65 mg/dL (3.61 mmol/L) in a client with radiation enteritis who is receiving total parenteral nutrition
Correct Answer: C
Rationale: A serum glucose of 65 mg/dL indicates hypoglycemia, which is critical in a client on total parenteral nutrition, as it may require immediate adjustment of glucose infusion or administration of dextrose.
A 9 year-old is taken to the emergency room with right lower quadrant pain and vomiting. When preparing the child for an emergency appendectomy, what must the nurse expect to be the child's greatest fear?
- A. Change in body image
- B. An unfamiliar environment
- C. Perceived loss of control
- D. Guilt over being hospitalized
Correct Answer: C
Rationale: For school-age children, major fears are loss of control and separation from friends/peers.