Nokea
A chronic alcoholic client's condition deteriorates, and he begins to exhibit signs of hepatic coma. Which of the following is an early sign of impending hepatic coma?
- A. Hiccups
- B. Anorexia
- C. Mental confusion
- D. Fetor hepaticus
Correct Answer: C
Rationale: One of the earliest symptoms of hepatic coma is mental confusion. Asterixis, a flapping tremor of the hand, may also be seen.
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After 7 hours in restraints and a total of 30-mg haloperidol in divided doses, a client complains of stiffness in his neck and his tongue 'pulling to one side.' These extrapyramidal symptoms (EPS) will most likely be relieved by the administration of:
- A. Lorazepam (Ativan)
- B. Benztropine (Cogentin)
- C. Thiothixene (Navane)
- D. Flurazepan (Dalmane)
Correct Answer: B
Rationale: Benztropine acts to reduce EPS by blocking excess CNS cholinergic activity associated with dopamine deficiency in the basal ganglia by displacing acetylcholine at the receptor site.
The physician has ordered aerosol treatments, chest percussion, and postural drainage for a client with cystic fibrosis. The nurse recognizes that the combination of therapies is to:
- A. Decrease respiratory effort and mucous production
- B. Increase efficiency of the diaphragm and gas exchange
- C. Dilate the bronchioles and help remove secretions
- D. Stimulate coughing and oxygen consumption
Correct Answer: C
Rationale: These therapies aim to dilate airways (aerosols), mobilize mucus (percussion), and clear secretions (postural drainage) to improve breathing in cystic fibrosis.
The nurse is caring for a client with a brain tumor who has been prescribed levofloxacin (Levaquin) for a sinus infection. What specific instructions should be included when educating the client regarding taking this drug?
- A. Avoid direct sunlight.
- B. Report unexplained joint pain.
- C. No antacids should be taken within 2 hours of taking the drug.
- D. Take the medication on an empty stomach.
- E. Keep the head of the bed elevated for 30 minutes after taking.
Correct Answer: A, B, C
Rationale: Levofloxacin requires avoiding sunlight (A) due to photosensitivity, reporting joint pain (B) for tendonitis risk, and avoiding antacids (C) to ensure absorption. Empty stomach (D) is optional, and bed elevation (E) is unrelated.
The nurse is assessing elderly clients at a community center.
- A. Dry mouth
- B. Loss of one inch of height in the last year
- C. Stiffened joints
- D. Rales bilaterally on chest auscultation
Correct Answer: D
Rationale: Rales bilaterally indicate possible pulmonary edema or infection, which are serious conditions requiring immediate attention. Dry mouth (A), height loss (B), and stiffened joints (C) are common in aging but less urgent.
A client was admitted to the hospital after falling in her home. At the time of admission, her blood alcohol level was 0.27 mg%. Her family indicates that she has been drinking a fifth of vodka a day for the past 9 months. She had her last drink 30 minutes prior to admission. Alcohol withdrawal symptoms would most likely be exhibited by her:
- A. Two to 4 hours after the last drink
- B. Six to 8 hours after the last drink
- C. Immediately on admission
- D. Twenty-four hours after the last drink
Correct Answer: B
Rationale: This answer is incorrect. Alcohol withdrawal usually begins approximately 6-8 hours after the last drink. This answer is correct. It takes approximately 6-8 hours for metabolism of alcohol. This answer is incorrect. The alcohol is still in the system, as indicated by the high blood alcohol level. This answer is incorrect. Symptoms of alcohol withdrawal usually begin within 6-8 hours of the last drink.