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A client is admitted with Parkinson's disease. The client has been taking Carbidopa/levodopa (Sinemet) for 1 year. Which clinical manifestation would be the most important to report?
- A. Dry mouth
- B. Spasmodic eye winking
- C. Dark urine
- D. Dizziness
Correct Answer: B
Rationale: Spasmodic eye winking could indicate a toxicity or overdose and should be reported to the physician. Other signs of toxicity include involuntary twitching of muscles, facial grimaces, and severe tongue protrusion. Answers A, C, and D are incorrect because they are side effects of the drug.
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The parents of a 15 month-old child asks the nurse to explain their child's lab results and how they show the child has iron deficiency anemia. The nurse's best response is
- A. Although the results are here, your doctor will explain them later.
- B. Your child has fewer red blood cells that carry oxygen.
- C. The blood cells that carry nutrients to the cells are too large.
- D. There are not enough blood cells in your child's circulation.
Correct Answer: B
Rationale: Your child has fewer red blood cells that carry oxygen. This provides a simple explanation of iron deficiency anemia.
The nurse administers the prescribed dose of hydromorphone 2 mg to a client who had knee replacement surgery 2 days ago. Which assessment finding is most concerning to the nurse?
- A. Client falls asleep while talking to the nurse
- B. Client has had no bowel movement for 2 days
- C. Client has one episode of nonbilious emesis
- D. Client reports experiencing pruritus
Correct Answer: A
Rationale: Falling asleep mid-conversation (A) may indicate opioid-induced respiratory depression, a life-threatening concern. Constipation (B), emesis (C), and pruritus (D) are less urgent side effects.
The nurse is talking with a client with atrial fibrillation who has a new prescription for dabigatran. Which of the following statements by the client would require follow-up?
- A. I should use a soft-bristled toothbrush when brushing my teeth.'
- B. I will notify my health care provider if I notice blood in my urine or stool.'
- C. I should swallow the medication capsule whole with a full glass of water.'
- D. I will have blood specimens obtained periodically while taking the medication.'
Correct Answer: D
Rationale: Dabigatran does not require routine blood monitoring (D), unlike warfarin, so this statement requires follow-up. Soft toothbrush (A), reporting bleeding (B), and swallowing whole (C) are correct.
The clinic nurse evaluates a client who was prescribed lithium therapy a month ago for bipolar disorder. Which client statement would cause the most concern?
- A. I've felt the need for an afternoon nap most days this week.'
- B. I've gained 3 lb (1.36 kg) since I began taking this medication.'
- C. I've had the stomach flu for the past couple of days.'
- D. My mouth seems to be drier than usual lately.'
Correct Answer: C
Rationale: Stomach flu (C) can cause dehydration, increasing lithium toxicity risk, requiring immediate concern. Naps (A), weight gain (B), and dry mouth (D) are less urgent side effects.
The LPN/LVN is providing home care to an elderly widow who has senile dementia. The woman tells the nurse that her daughter hits her and tells her to shut up. The nurse notes one ecchymotic area on the client's right forearm. The daughter seems attentive to the woman when the nurse is present. What action should the nurse take?
- A. Immediately call the police
- B. Ask the daughter why she abuses her mother
- C. Ask the physician to order long bone x-rays
- D. Report the woman's remarks and the nurse's findings to the nursing supervisor
Correct Answer: D
Rationale: Reporting suspected abuse to the supervisor initiates investigation and protection, the appropriate action for potential elder abuse.