Nokea
A 24-year-old client presents to the emergency department protesting 'I am God.' The nurse identifies this as a:
- A. Delusion
- B. Illusion
- C. Hallucination
- D. Conversion
Correct Answer: A
Rationale: A delusion is a false belief, such as claiming to be God, common in psychotic disorders.
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Iron dextran (Imferon) is a parenteral iron preparation. The nurse should know that it:
- A. Is also called intrinsic factor
- B. Must be given in the abdomen
- C. Requires use of the Z-track method
- D. Should be given SC
Correct Answer: C
Rationale: The Z-track method prevents staining and irritation when administering iron dextran parenterally in a large muscle.
The mother of a child with chickenpox wants to know if there is a medication that will shorten the course of the illness. Which medication is sometimes used to speed healing of the lesions and shorten the duration of fever and itching?
- A. Zovirax (acyclovir)
- B. Varivax (varicella vaccine)
- C. VZIG (varicella-zoster immune globulin)
- D. Periactin (cyproheptadine)
Correct Answer: A
Rationale: Acyclovir (Zovirax) is an antiviral that can reduce the severity and duration of chickenpox symptoms, including lesions, fever, and itching.
The physician has ordered intravenous fluid with potassium for a client admitted with gastroenteritis and dehydration. Before adding potassium to the intravenous fluid, the nurse should:
- A. Assess the urinary output.
- B. Obtain arterial blood gases.
- C. Perform a dextrostick.
- D. Obtain a stool culture.
Correct Answer: A
Rationale: Potassium supplementation requires adequate renal function to prevent hyperkalemia. Assessing urinary output ensures the kidneys are functioning before adding potassium.
A client with a history of a stroke is receiving Plavix (clopidogrel). The nurse should monitor the client for:
- A. Bleeding
- B. Hypertension
- C. Hypoglycemia
- D. Fever
Correct Answer: A
Rationale: Clopidogrel, an antiplatelet, increases bleeding risk, requiring monitoring for signs like bruising or epistaxis. Hypertension, hypoglycemia, and fever are not primary concerns.
A mother brings a 6-month-old infant and a 4-year-old child to the nursing clinic for routine examination and screening. Which of these plans by the nurse would be most successful?
- A. Examine the 4 year old first.
- B. Provide time for play and becoming acquainted.
- C. Have the mother leave the room with one child, and examine the other child privately.
- D. Examine painful areas first to get them 'over with.'
Correct Answer: B
Rationale: The 6 month old should be examined first. If several children will be examined, begin with the most cooperative and less anxious child to provide modeling. Providing time for play and getting acquainted minimizes stress and anxiety associated with assessment of body parts. Children generally cooperate best when their mother remains with them. Painful areas are best examined last and will permit maximum accuracy of assessment.