Nokea
A client has been taking perphenazine (Trilafon) by mouth for two days and now displays the following: head turned to the side, neck arched at an angle, stiffness and muscle spasms in neck. The nurse would expect to give which of the following as a PRN medication?
- A. Promazine (Sparine).
- B. Biperiden (Akineton).
- C. Thiothixene (Navane).
- D. Haloperidol (Haldol).
Correct Answer: B
Rationale: The symptoms describe acute dystonia, an extrapyramidal side effect of perphenazine. Biperiden, an antiparkinsonian agent, counteracts these effects. Promazine, thiothixene, and haloperidol (A, C, D) are antipsychotics and would not relieve dystonia.
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For which of the following conditions might blood be drawn for uric acid level?
- A. asthma
- B. gout
- C. diverticulitis
- D. meningitis
Correct Answer: B
Rationale: Gout is characterized by elevated uric acid levels, which are measured to confirm diagnosis and monitor treatment. The other conditions do not typically involve uric acid testing. Reduction of Risk Potential
Prochlorperazine maleate (Compazine) 10 mg IM has been ordered for a client. The client is also to receive Stadol 2 mg IM. Before administering these medications, the nurse should
- A. obtain respirations and temperature.
- B. dilute with 9 ml of NS.
- C. draw the medications in separate syringes.
- D. verify the route of administration.
Correct Answer: C
Rationale: Compazine (prochlorperazine) is incompatible with most medications, including Stadol (butorphanol), in the same syringe, as mixing may cause precipitation or reduced efficacy. Drawing them in separate syringes ensures safe administration. Monitoring vital signs (A) is less critical, dilution (B) is inappropriate, and verifying the route (D) is unnecessary as IM is specified.
B.C. is a 14-yr-old boy who was brought to the ER after he had sustained flame burns. He had been wearing masquerade costume during Halloween celebration when his costume was set ablaze by the lighted candles in the party room. He extinguished the fire by rolling on the floor. On admission, resuscitation was commenced with intravenous fluids, antibiotics, and wound dressing. On examination he was found to be a young man, not pale, but febrile (body temperature, 37.8°C). He was tachypneic, RR 26 per min, with audible breath sounds bilaterally. Burn assessment revealed a total body surface area involved of 30%, with mixed-thickness burns sparing some patchy areas of the back and the right upper limb. B.C. anterior chest was affected.
For the first 24 hours after hospitalization, the nurse should primarily observe him for
- A. wound sepsis.
- B. complain of pain.
- C. dyspnea or stridor.
- D. initiate IV therapy.
Correct Answer: C
Rationale: Inhalation burns are usually present with facial burns, regardless of the depth; the immediate threat to life is asphyxia from irritation and edema of the respiratory passages and lungs.
A 35-year-old male has been an insulin-dependent diabetic for five years and now is unable to urinate.
Which of the following would you most likely suspect?
- A. Atherosclerosis
- B. Diabetic neuropathy
- C. Autonomic neuropathy
- D. Somatic neuropathy
Correct Answer: C
Rationale: Autonomic neuropathy can impair bladder function, causing urinary retention in long-term diabetes.
A diet rich in calcium over a lifetime will decrease the risk of
Heart disease
- A. Osteoporosis
- B. Gout
- C. Rheumatoid Arthritis
Correct Answer: B
Rationale: A diet rich in calcium over a lifetime will decrease the risk of osteoporosis by strengthening bones.