Nokea
A client is being followed in the rape-crisis clinic one week after being assaulted. The client is currently taking Xanax 0.25 mg PO q6h for anxiety. Which of the following statements, if made by the client to the nurse, reflects a correct understanding of this medication?
- A. I can take it whenever I feel upset.
- B. I should not take this with anything but water.
- C. I guess I need to stop drinking white wine.
- D. This medication will help me forget and go on.
Correct Answer: C
Rationale: Alcohol, including white wine, potentiates Xanax’s sedative effects, increasing risks. Avoiding it shows understanding. Options A, B, and D are incorrect.
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A client with a peptic ulcer had a partial gastrectomy and vagotomy (Billroth I).
- A. What should the nurse caution the client about to prevent dumping syndrome post-gastrectomy?
- B. Sit up for at least 30 minutes after eating.
- C. Avoid fluids between meals.
- D. Increase the intake of high-carbohydrate foods.
- E. Avoid eating large meals that are high in simple sugars and liquids.
Correct Answer: D
Rationale: To prevent dumping syndrome, the client should avoid large meals high in simple sugars and liquids, which can cause rapid gastric emptying. The client should recline after meals, drink fluids between meals, and reduce carbohydrate intake to stabilize digestion.
A three-year-old boy was shown to have delays on the Denver Development Screening Test (DDST).
Which of the following responses by the nurse is BEST?
- A. Maybe he is just having a bad day. I'm sure he will do much better next time.
- B. The Test indicated a delay and we will have to investigate to learn more.
- C. What are your thoughts about how your child performed on the Test ?
- D. The results may not be accurate. Let's set up a time to reTest your child.
Correct Answer: C
Rationale: Strategy: 'BEST' indicates that fine discrimination is required. The topic of the questions is unstated. Determine topic by reading the answer choices. (1) nontherapeutic, false reassurance (2) factual but closed communication (3) correct-open-ended, encourages discussion (4) doesn't encourage discussion of concerns
The nurse is caring for a client who had a myocardial infarction yesterday and received alteplase (tPA). The client's spouse asks the nurse why that medication was given. What should the nurse include when replying?
- A. Alteplase (tPA) is given to relieve the pain of a heart attack.
- B. Alteplase (tPA) dissolves the clot that is blocking a coronary artery.
- C. Alteplase (tPA) prevents new clots from forming and existing clots from getting bigger.
- D. Alteplase (tPA) helps the heart muscle to repair itself.
Correct Answer: B
Rationale: Alteplase (tPA) is a thrombolytic drug and dissolves the clot that is blocking a coronary artery. It does not relieve pain, prevent new clots from forming, or help the heart muscle to heal.
A client asks the home care nurse to look at the bruises on her arms and legs. The woman also tells the nurse that her gums bleed when she uses dental floss or brushes her teeth. The client is taking all of the following medications. Which is most likely related to the client's symptoms?
- A. Metformin (Glucophage)
- B. Estrogen (Premarin)
- C. Atenolol (Tenormin)
- D. Ibuprofen (Motrin)
Correct Answer: D
Rationale: Ibuprofen, an NSAID, can inhibit platelet function, causing bruising and bleeding gums. Other medications are less likely to cause these symptoms.
A 55-year-old woman with end-stage metastatic cancer of the breast is admitted to the hospital. It is MOST important for the nurse to
- A. suction the patient frequently.
- B. provide an air mattress.
- C. turn the patient every two hours.
- D. give the patient frequent baths.
Correct Answer: C
Rationale: Turning every two hours prevents pressure ulcers in immobile cancer patients, a priority for skin integrity. Options A, B, and D are less critical unless specifically indicated.