Nokea
A client is admitted with an epidural hematoma after a skateboarding accident. How should the nurse differentiate the vascular source of intracranial bleeding?
- A. Monitor for clear fluid leakage from the nose.
- B. Assess for rapid onset of decreased level of consciousness.
- C. Check for bruising around the head and neck.
- D. Assess for changes in pupil size and reactivity.
Correct Answer: B
Rationale: An epidural hematoma is characterized by a rapid onset of symptoms, including decreased level of consciousness, due to arterial bleeding, which differentiates it from other types of intracranial hemorrhage. Monitoring for clear fluid leakage from the nose (choice A) is more indicative of a basilar skull fracture and cerebrospinal fluid leak. Checking for bruising around the head and neck (choice C) is more suggestive of soft tissue injuries or facial fractures. Assessing for changes in pupil size and reactivity (choice D) is essential in evaluating traumatic brain injuries, but it is not specific to differentiating the vascular source of intracranial bleeding in an epidural hematoma.
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A client with hypothyroidism is prescribed levothyroxine. What assessment finding suggests the medication is effective?
- A. Improved tolerance to cold.
- B. Decreased fatigue and improved energy levels.
- C. Reduced anxiety and improved mood.
- D. Increased sensitivity to heat.
Correct Answer: B
Rationale: The correct answer is B: Decreased fatigue and improved energy levels. Levothyroxine is a medication used to treat hypothyroidism by providing the body with the thyroid hormone it lacks. Therefore, a positive response to the medication would manifest as decreased fatigue and improved energy levels due to the correction of the thyroid hormone imbalance. Choices A, C, and D are incorrect because improved tolerance to cold, reduced anxiety, and increased sensitivity to heat are not direct indicators of the effectiveness of levothyroxine in managing hypothyroidism.
A client undergoing chemotherapy reports extreme fatigue. What should the nurse recommend to manage this symptom?
- A. Increase the dose of chemotherapy.
- B. Rest when needed and maintain a balanced diet.
- C. Perform light physical activity to reduce fatigue.
- D. Consider delaying the chemotherapy treatment.
Correct Answer: B
Rationale: The correct recommendation for managing chemotherapy-induced fatigue is to advise the client to rest when needed and maintain a balanced diet. Increasing the dose of chemotherapy (Choice A) would exacerbate the fatigue and other side effects. While light physical activity (Choice C) can be beneficial, extreme fatigue may require more rest initially. Delaying chemotherapy treatment (Choice D) should only be considered after consultation with the healthcare provider, as timely treatment is usually crucial in cancer care.
A male client with heart failure becomes short of breath, anxious, and has pink frothy sputum. What is the first action the nurse should take?
- A. Consult the charge nurse about administering morphine.
- B. Administer the morphine sulfate as prescribed.
- C. Withhold the morphine until the dyspnea resolves.
- D. Review the need for the morphine prescription with the provider.
Correct Answer: B
Rationale: The correct answer is B: Administer the morphine sulfate as prescribed. In this situation, the client is experiencing symptoms of acute pulmonary edema, a complication of heart failure. Morphine is indicated as it helps reduce anxiety and respiratory distress by decreasing preload and afterload. It dilates blood vessels, reducing the workload of the heart and improving oxygenation. The priority is to administer the morphine promptly to alleviate the client's distress and improve oxygenation. Consulting the charge nurse (A) or reviewing the need for the morphine prescription with the provider (D) would cause a delay in providing essential treatment. Withholding the morphine (C) would not be appropriate as it is indicated for this condition.
The nurse is planning to administer two medications at 0900. Which property of the drugs indicates a need to monitor the client for toxicity?
- A. Short half-life
- B. High therapeutic index
- C. Highly protein-bound
- D. Low bioavailability
Correct Answer: C
Rationale: The correct answer is C, 'Highly protein-bound.' Drugs that are highly protein-bound can displace from protein-binding sites, leading to increased free drug levels in the blood, which can result in toxicity. Monitoring the client for toxicity is crucial when administering highly protein-bound drugs. Choices A, B, and D are incorrect. A short half-life does not necessarily indicate a need for monitoring toxicity; a high therapeutic index indicates a wide safety margin between the effective dose and the toxic dose, reducing the risk of toxicity; low bioavailability refers to the fraction of the drug that reaches the systemic circulation unchanged and does not directly relate to the risk of toxicity.
A client with tuberculosis (TB) is being discharged on isoniazid and rifampin. What instruction should the nurse prioritize?
- A. Complete the full course of antibiotics.
- B. Notify the healthcare provider if you experience tingling in your fingers.
- C. Use a disposable mask when in contact with others.
- D. Monitor liver function tests monthly.
Correct Answer: C
Rationale: The correct answer is to instruct the client to use a disposable mask when in contact with others. TB is highly contagious, and wearing a mask can help prevent the spread of the disease to others. Choice A is important but not the priority as using a mask directly impacts public health. Choice B is related to a potential side effect of isoniazid, peripheral neuropathy, but immediate healthcare provider notification is not required. Choice D is relevant due to the potential hepatotoxicity of isoniazid and rifampin, but it is not the priority instruction in this scenario.