Nokea
A client has been placed on the drug valproic acid (Depakene). Which would indicate to the nurse that the client is experiencing an adverse reaction to this medication?
- A. Photophobia
- B. Poor skin turgor
- C. Lethargy
- D. Visual disturbances
Correct Answer: C
Rationale: Lethargy is a common adverse reaction to valproic acid, indicating potential toxicity or side effects, requiring further evaluation.
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A client admitted with hepatic encephalopathy continues to attempt ambulation without assistance despite repeated instruction. Which intervention should the nurse take to promote safety?
- A. administer Xanax 6 mg PO
- B. apply a vest restraint device
- C. request a family member stay with the client around the clock
- D. move the client closer to the nurses' station
Correct Answer: D
Rationale: Moving the client closer to the nurses’ station allows frequent monitoring, promoting safety without restraints or sedation, which are less appropriate.
The nurse finds that a client receiving digoxin (Lanoxin) 0.25 mg orally has an apical pulse of 54. Which of the following should the nurse do first?
- A. withhold the medicine and contact the prescribing physician
- B. ask another nurse to verify the apical pulse
- C. administer the medication and recheck the pulse in 30 minutes
- D. order a stat ECG
Correct Answer: A
Rationale: An apical pulse of 54 is below the safe threshold (typically 60) for digoxin, indicating potential toxicity. Withholding the dose and notifying the provider is the priority.
In planning care for the patient with ulcerative colitis, the nurse identifies which nursing diagnosis as a priority?
- A. Anxiety
- B. Impaired skin integrity
- C. Fluid volume deficit
- D. Nutrition altered, less than body requirements
Correct Answer: C
Rationale: Fluid volume deficit is a priority in ulcerative colitis due to frequent diarrhea, which can lead to dehydration.
A client is admitted with a diagnosis of pernicious anemia. Which of the following signs or symptoms would indicate that the client has been noncompliant with ordered B12 injections?
- A. Hyperactivity in the evening hours
- B. Weight gain of 5 pounds in 1 week
- C. Paresthesia of hands and feet
- D. Diarrhea stools several times a day
Correct Answer: C
Rationale: Pernicious anemia causes B12 deficiency, leading to neurological symptoms like paresthesia. Noncompliance with B12 injections would result in persistent or worsening paresthesia.
A pediatric client with burns to the hands and arms has dressing changes with Sulfamylon (mafenide acetate) cream. The nurse is aware that the medication:
- A. Will cause dark staining of the surrounding skin
- B. Produces a cooling sensation when applied
- C. Can alter the function of the thyroid
- D. Produces a burning sensation when applied
Correct Answer: D
Rationale: Sulfamylon (mafenide acetate) causes a burning sensation upon application, which should be explained to the client.