Nokea
A client diagnosed with trigeminal neuralgia is given a prescription of carbamazepine by the health care provider. Which intervention does the nurse anticipate in this client's care plan?
- A. Encourage client to drink cold beverages
- B. Encourage client to eat a high-fiber diet
- C. Encourage client to perform facial massage
- D. Encourage client to report any fever or sore throat
Correct Answer: D
Rationale: Carbamazepine can cause agranulocytosis or infections; fever or sore throat must be reported. Cold beverages may trigger trigeminal neuralgia pain. High-fiber diets and facial massage are unrelated to management.
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The nurse is caring for a man who had a transsphenoidal hypophysectomy earlier today. He says he has to spit a lot. What nursing action is essential?
- A. Ask him to blow his nose.
- B. Do a glucose test on his mouth secretions.
- C. Have him rinse his mouth with water.
- D. Ask him if he needs an antiemetic.
Correct Answer: B
Rationale: Excessive spitting may indicate cerebrospinal fluid (CSF) leak, which contains glucose; testing secretions confirms this serious complication.
The nurse is teaching a client about communicable diseases and explains that a portal of entry is:
- A. a vector.
- B. a source, like contaminated water.
- C. food.
- D. the respiratory system.
Correct Answer: D
Rationale: The path by which a microorganism enters the body is the portal of entry. A vector is a carrier of disease, a source (like bad water or food) can be a reservoir of disease.
Clients taking lithium must be particularly sure to maintain adequate intake of which of these elements?
- A. Potassium
- B. Sodium
- C. Chloride
- D. Calcium
Correct Answer: B
Rationale: Clients taking lithium need to maintain an adequate intake of sodium. Serum lithium concentrations may increase in the presence of conditions that cause sodium loss.
Continuous bladder irrigation is prescribed for an adult who had bladder surgery; 1000 mL of irrigating solution was instilled in the last eight hours. The amount of drainage in the urine drainage bag for the last eight hours is 1700 mL. How much is the client's urine output for the last eight hours?
- A. 270 mL
- B. 700 mL
- C. 1700 mL
- D. 2799 mL
Correct Answer: B
Rationale: Urine output is calculated by subtracting instilled irrigation fluid (1000 mL) from total drainage (1700 mL), yielding 700 mL of actual urine.
The spouse of a client calls the nurse at the clinic and reports that the client is not feeling well and is concerned that something is seriously wrong. How should the nurse respond initially?
- A. Ask the spouse to further describe the client's symptoms
- B. Indicate that privacy rules prevent discussion of concerns with the spouse
- C. Offer a same-day appointment to the client
- D. Tell the spouse to have the client call the nurse
Correct Answer: A
Rationale: Asking for symptom details helps assess urgency without violating privacy, as the spouse initiated contact. Privacy rules don't preclude initial fact-gathering, but direct client contact or an appointment may follow based on severity.