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Prior to discharge of a child with a ventriculoperitoneal (VP) shunt, the nurse reinforces teaching to the caregiver about when to contact the health care provider. The caregiver shows understanding of the instructions by contacting the health care provider about which symptom?
- A. A temperature of 98.6°F (37.2°C) that occurs during the evening
- B. The child cannot recall items eaten for lunch the previous day
- C. The child vomits after awakening from a nap and again 1 hour later
- D. The VP shunt is palpable along the posterolateral portion of the skull
Correct Answer: C
Rationale: Persistent vomiting (C) suggests shunt malfunction or increased intracranial pressure, requiring immediate reporting. Normal temperature (A), memory lapses (B), and palpable shunt (D) are not concerning.
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A client with active pulmonary tuberculosis is prescribed 4-drug therapy with ethambutol. The nurse reinforces previous teaching to notify the health care provider immediately if which adverse effect associated with ethambutol occurs?
- A. Blurred vision
- B. Dark-colored urine
- C. Difficulty hearing
- D. Yellow skin
Correct Answer: A
Rationale: Ethambutol can cause optic neuritis, leading to blurred vision (A), a serious side effect requiring immediate reporting. Dark urine (B), hearing loss (C), and jaundice (D) are associated with other TB drugs (e.g., rifampin, isoniazid).
During the charge nurse’s morning rounds, a client says, 'I hope you will take better care of me than the nurse I had last night.' What should be the charge nurse’s initial response?
- A. Apologize for the previous nurse’s treatment
- B. Ask the client to describe what happened last night
- C. Explain that the night nurse was probably busy
- D. Reassure the client that things will be better today
Correct Answer: B
Rationale: Asking for details (B) allows the charge nurse to understand the client’s concerns and address specific issues. Apologizing (A) assumes fault, excusing the nurse (C) dismisses the concern, and reassurance (D) lacks follow-through without investigation.
A young adult is admitted with a possible head injury. The car in which he was riding hit a utility pole, and the client's head hit the windshield. Baseline vital signs are BP=112/74, P=80, and R=12. The nurse checks the client an hour after admission. Which finding(s) are significant and should be reported to the charge nurse or physician immediately? Select all that apply.
- A. BP=126/68
- B. Pulse=62
- C. Respirations=8
- D. Projectile vomiting
- E. Client's skin is cool to the touch.
- F. Both pupils respond to exposure to flashlight by constricting.
Correct Answer: C,D
Rationale: Slow respirations (8) and projectile vomiting suggest increased intracranial pressure, critical in head injury, requiring immediate reporting. BP, pulse, skin, and pupil response changes are less urgent.
The nurse is reinforcing discharge teaching with the parent of a 6-year-old client who had a tonsillectomy 4 hours ago. The nurse should reinforce that it would be a priority to notify the health care provider if the client experiences
- A. Ear pain
- B. Foul-smelling breath
- C. Frequent swallowing
- D. Low-grade fever
Correct Answer: C
Rationale: Frequent swallowing (C) may indicate bleeding, a serious post-tonsillectomy complication requiring immediate reporting. Ear pain (A), bad breath (B), and low-grade fever (D) are common and less urgent.
A client taking Zoloft (sertraline) tells the nurse that she has also been taking St. John's wort. The nurse should report this information to the doctor because:
- A. The two substances have opposing effects.
- B. The amount of medication may be reduced.
- C. Herbals only provide a placebo effect.
- D. It will be necessary to increase the dosage.
Correct Answer: B
Rationale: St. John's wort can induce the metabolism of Zoloft, potentially reducing its effectiveness, so the doctor may need to adjust the dose. Answer A is incorrect as they do not have opposing effects. Answer C is incorrect as St. John's wort has pharmacological effects. Answer D is incorrect as increasing the dose may not be necessary.