Nokea
A client has been hospitalized with heart failure. He is receiving digoxin (Lanoxin) and furosemide (Lasix) intravenously. He tells the nurse that he hears a continuous ringing in his ears and that he has never had this problem before. What is the appropriate action for the nurse to take at this time?
- A. Obtain a digoxin level to check for toxicity
- B. Note the observation in the chart and plan to reassess in 2 hours
- C. Ask the client if he has been taking aspirin in addition to his other medications
- D. Discontinue the furosemide and notify the physician
Correct Answer: A
Rationale: Ringing in the ears (tinnitus) is a sign of digoxin toxicity, requiring immediate checking of digoxin levels. Aspirin is less likely to cause this, and discontinuing furosemide or delaying action is inappropriate.
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A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed tiotropium (Spiriva). The nurse should instruct the client to:
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after inhalation.
- C. Take the inhaler with meals.
- D. Stop the inhaler if dizziness occurs.
Correct Answer: B
Rationale: Rinsing the mouth after tiotropium inhalation prevents oral thrush.
Which sound should you expect to hear when you percuss the liver during a complete physical assessment?
- A. Resonance
- B. Flatness
- C. Tympany
- D. Dullness
Correct Answer: D
Rationale: The liver, a solid organ, produces a dull sound when percussed, as opposed to the tympanic sound of air-filled structures or the resonant sound of lung tissue.
The nurse is caring for a client who has just undergone a total hip replacement. Which of the following positions should the nurse avoid placing the client in?
- A. Supine with legs crossed.
- B. Semi-Fowler's position.
- C. Side-lying with a pillow between the legs.
- D. Supine with the legs abducted.
Correct Answer: A
Rationale: Crossing the legs post-hip replacement risks dislocation of the prosthesis and should be avoided.
A client with a diagnosis of nephrotic syndrome states to the nurse, 'Why should I even bother trying to control my diet and the swelling? It doesn't really matter what I do if I can never get rid of this kidney problem anyway!' Which potential client problem should the nurse address based on the client's statement?
- A. Anxiety
- B. Difficulty coping
- C. Feeling powerless
- D. Negative body image
Correct Answer: C
Rationale: Feeling powerless is a problem when the client believes that personal actions will not affect an outcome in any significant way. Anxiety occurs when the client has a feeling of unease with a vague or undefined source. Difficulty coping indicates that the client has impaired adaptive abilities or behaviors in meeting the demands or roles expected from the individual. Negative body image occurs when the way the client perceives body image is altered.
Select the types and stages of conflict that are accurately paired with their description. Select all that apply.
- A. Frustration: The phase of conflict that is characterized with personal agendas and obstruction
- B. Conceptualization: The phase of conflict that occurs when contending parties have developed a clear and objective understanding of the nature of the conflict and factors that have led to it
- C. Taking action: The phase of conflict that is characterized with individual responses to and feelings about the conflict
- D. Resolution: The type of conflict that can be resolved
- E. Avoidance-Avoidance: A stage of conflict that occurs when there are NO alternatives that are acceptable to the contending parties
- F. Approach- Approach Conflicts: The type of conflict that occurs when the people involved in the conflict want more than one alternatives or actions that could resolve the conflict.
- G. Approach-Avoidance Conflicts: The type of conflict that occurs when the people involved in the conflict believe that all of the alternatives are NEITHER completely satisfactory nor completely dissatisfactory.
Correct Answer: B,D,F,G
Rationale: Conceptualization is correctly described as understanding the conflict's nature. Resolution refers to conflicts that can be resolved. Approach-Approach (F) involves choosing between desirable alternatives, and Approach-Avoidance (G) involves alternatives with both positive and negative aspects. Frustration is not about personal agendas but emotional responses, Taking action involves implementing solutions, not just feelings, and Avoidance-Avoidance is a type, not a stage, of conflict.